Provider Demographics
NPI:1104992429
Name:WALEN, HARRY (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:WALEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 QUARRY LAKE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3744
Mailing Address - Country:US
Mailing Address - Phone:410-415-5806
Mailing Address - Fax:410-415-6620
Practice Address - Street 1:2700 QUARRY LAKE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3744
Practice Address - Country:US
Practice Address - Phone:410-415-5806
Practice Address - Fax:410-415-6620
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0010718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD35880170Medicaid
MD35880170Medicaid
MDB69833Medicare UPIN
MD004LMedicare ID - Type UnspecifiedGROUP PROVIDER