Provider Demographics
NPI:1427284595
Name:GATEWAY PEDIATRICS, LLC
Entity type:Organization
Organization Name:GATEWAY PEDIATRICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-912-7000
Mailing Address - Street 1:1415 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-7130
Mailing Address - Country:US
Mailing Address - Phone:410-912-7000
Mailing Address - Fax:410-912-4202
Practice Address - Street 1:1415 WESLEY DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-7130
Practice Address - Country:US
Practice Address - Phone:410-912-7000
Practice Address - Fax:410-912-4202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2100215P0001Medicaid