=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417146200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. FOGEL AND GOTTLIEB, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2007
-----------------------------------------------------
Last Update Date | 11/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 YORK RD LOWER LEVEL
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-7616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-279-0130
-----------------------------------------------------
Fax | 443-279-0131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 YORK RD LOWER LEVEL
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-7616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-279-0130
-----------------------------------------------------
Fax | 443-279-0131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SANDY LEWIS FOGEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 443-279-0130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | D30420
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------