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General NPI Number Information
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NPI Number | 1730816471
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Entity Type | Individual
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Provider Name | MRS. MARY ELLEN EBERSOLE
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Gender | Female
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Dates
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Enumeration Date | 08/03/2022
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Last Update Date | 08/03/2022
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Provider Practice Location Address
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Address Line | 10632 LITTLE PATUXENT PKWY STE 441
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City | COLUMBIA
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State | MD
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Zip | 21044-6260
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Country | US
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Telephone | 410-720-4245
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Fax |
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Provider Business Mailing Address
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Address Line | 11038 MONTGOMERY RD
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City | BELTSVILLE
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State | MD
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Zip | 20705-2816
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Country | US
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Telephone | 301-704-0882
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | E01074
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License Number State | MD
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