Provider Demographics
NPI:1427363795
Name:BRIAN E MONDELL, MD LLC
Entity type:Organization
Organization Name:BRIAN E MONDELL, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MONDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-321-4558
Mailing Address - Street 1:2331 OLD COURT RD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3422
Mailing Address - Country:US
Mailing Address - Phone:410-321-4558
Mailing Address - Fax:410-494-1047
Practice Address - Street 1:14 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1712
Practice Address - Country:US
Practice Address - Phone:410-276-1773
Practice Address - Fax:410-276-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032496261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE00537Medicare UPIN