Provider Demographics
NPI:1285490011
Name:MATHIS, MELVIN SYLVESTER (MED)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:SYLVESTER
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-0704
Mailing Address - Country:US
Mailing Address - Phone:410-274-6689
Mailing Address - Fax:
Practice Address - Street 1:2709 KIRK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4810
Practice Address - Country:US
Practice Address - Phone:410-274-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD276400000X, 324500000X
276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit