Provider Demographics
NPI:1154434116
Name:INFECTIOUS DISEASE ASSOCIATES, P.A.
Entity type:Organization
Organization Name:INFECTIOUS DISEASE ASSOCIATES, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LANDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-418-8550
Mailing Address - Street 1:PO BOX 2377
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21041-2377
Mailing Address - Country:US
Mailing Address - Phone:410-418-8550
Mailing Address - Fax:
Practice Address - Street 1:2850 N RIDGE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3464
Practice Address - Country:US
Practice Address - Phone:410-418-8550
Practice Address - Fax:410-418-8552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057970207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG972OtherBLUECHOICE MARYLAND GRP #
MDKES7INOtherCAREFIRST, MARYLAND GRP #
MDDA5812OtherRAILROAD MEDICARE GROUP #
MD402077400Medicaid
MDH85144Medicare UPIN
MD402077400Medicaid