=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689690513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND ENT CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 07/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3333 N CALVERT ST STE 360
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-554-4455
-----------------------------------------------------
Fax | 410-554-2171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 N CALVERT ST BLDG SUITE631
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-552-2653
-----------------------------------------------------
Fax | 410-554-2171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | ANNETTE M MARTYN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-888-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------