=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225343825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND COLORECTAL SPECIALISTS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2010
-----------------------------------------------------
Last Update Date | 09/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 193 STONER AVE STE 130
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-751-1387
-----------------------------------------------------
Fax | 410-871-0603
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 193 STONER AVE STE 130
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-751-1387
-----------------------------------------------------
Fax | 410-871-0603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | ADWOA ANYADIKE
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 410-751-1387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number | D0070668
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------