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NPI Code Detail

MEDICARE: EYERUSALEM HAGOS

MEDICARE: EYERUSALEM HAGOS
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
1363LG0600XGerontology Nurse PractitionerR160719MD

General Provider Information

NPI Number : 1134662497
Entity Type Code : Individual
Provider Name (Legal Business Name) : EYERUSALEM HAGOS
Provider Business Mailing Address
First Line : 14226 MEADOW LAKE DR
Second Line :
City : GLENELG
State : MD
Zip : 21737-9604
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1 EASTERN BLVD
Second Line :
City : ESSEX
State : MD
Zip : 21221-7016
Country : US
Telephone Number : 310-707-6489
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/18/2016
Last Update Date : 11/18/2016

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Directions to “ EYERUSALEM HAGOS ” Practice Location

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