=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588303309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH MICHELLE ROERTY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2022
-----------------------------------------------------
Last Update Date | 05/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1838 GREENE TREE RD STE 245
-----------------------------------------------------
City | PIKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-7110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-944-3450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1630 WHETSTONE WAY APT 322
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21230-5155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-916-4464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------