=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578695821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN HENRY NEWBOLD M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1826 DUAL HIGHWAY
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-665-3800
-----------------------------------------------------
Fax | 301-416-7774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 277 POTOMAC HTS
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-791-4837
-----------------------------------------------------
Fax | 301-416-7774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D0041112
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------