Provider Demographics
NPI:1538221825
Name:UNIVERSITY OF MARYLAND ORAL MAXILLOFACIAL SURGERY ASSOC PA
Entity type:Organization
Organization Name:UNIVERSITY OF MARYLAND ORAL MAXILLOFACIAL SURGERY ASSOC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-706-6195
Mailing Address - Street 1:PO BOX 23531
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21203-5531
Mailing Address - Country:US
Mailing Address - Phone:410-706-6195
Mailing Address - Fax:410-706-4199
Practice Address - Street 1:650 W. BALTIMORE ST,
Practice Address - Street 2:SUITE 1401
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1501
Practice Address - Country:US
Practice Address - Phone:410-706-6195
Practice Address - Fax:410-706-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG320Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE COLET
MDF17157Medicare UPIN
MDI14704Medicare UPIN
MDV134Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE BERGM
MDS029Medicare PIN
MDH86282Medicare UPIN
MDJ384Medicare ID - Type UnspecifiedINIDIVDUAL MEDICARE CAC
MDAV44Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE ORD
MDT83571Medicare UPIN