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General NPI Number Information
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NPI Number | 1700830114
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Entity Type | Organization
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Legal Business Name | MIB PARTNERSHIP LLP
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Dates
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Enumeration Date | 05/20/2006
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 6715 N CHARLES ST
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City | BALTIMORE
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State | MD
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Zip | 21204-6822
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Country | US
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Telephone | 410-296-5610
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Fax | 410-296-2982
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Provider Business Mailing Address
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Address Line | PO BOX 630277
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City | BALTIMORE
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State | MD
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Zip | 21263-0277
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AGENT
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Name | MR. MICHAEL LISSE
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Credential |
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Telephone | 301-650-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M270
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License Number State | MD
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