MEDICARE: MID-ATLANTIC ALLERGY & ASTHMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	D46931	MD

General Provider Information

NPI Number	:	1063762417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-ATLANTIC ALLERGY & ASTHMA

Provider Business Mailing Address
First Line	:	6500 EARLY LILY ROW
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044
Country	:	US
Telephone Number	:	410-531-6466
Fax Number	:	410-531-6466

Provider Business Practice Location Address
First Line	:	8182 LARK BROWN ROAD
Second Line	:
City	:	ELKRIDGE
State	:	MD
Zip	:	21075
Country	:	US
Telephone Number	:	410-908-6466
Fax Number	:	410-531-6466

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL H GOLDMAN
Credential	:	M.D.
Telephone Number	:	410-908-6466

Provider Enumeration Date	:	09/13/2012
Last Update Date	:	09/13/2012

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