Provider Demographics
NPI:1063742013
Name:SHERIDAN PULMONARY GROUP LLC
Entity type:Organization
Organization Name:SHERIDAN PULMONARY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-687-6622
Mailing Address - Street 1:6830 HOSPITAL DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4373
Mailing Address - Country:US
Mailing Address - Phone:410-687-6622
Mailing Address - Fax:410-687-7039
Practice Address - Street 1:6830 HOSPITAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4373
Practice Address - Country:US
Practice Address - Phone:410-687-6622
Practice Address - Fax:410-687-7039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21846207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD256331200Medicaid
MD256331200Medicaid
MD7789Medicare PIN