Provider Demographics
NPI:1992882252
Name:DILLS, MARK STUART (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STUART
Last Name:DILLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 BALTIMORE ANNAPOLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1371
Mailing Address - Country:US
Mailing Address - Phone:410-544-7295
Mailing Address - Fax:
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-618-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000350363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00828Medicare UPIN
004997Medicare ID - Type Unspecified