Organization Name: | MEDSPA M.D. LLC |
NPI Number: | 1871848614 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | SUSAN RENEE CLANZY (CEO) |
Mailing Address: | 310 N Eutaw St Baltimore |
State: | MD US |
Postal Code: | 212011807 |
Phone Number: | 4106337721 |
Fax Number: | |
NPI Enumeration Date: | 07/18/2012 |
NPI Last Update Date: | 07/18/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | D0060902 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MD |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |