Organization
LAWRENCE VIDAVER MD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LOUISE MACY (BILLING MGR)
(410) 298-8223
Entity
Organization
Contact information
Practice address
1411 MADISON PARK DR, GLEN BURNIE, MD 21061-5613
(410) 761-1037
(410) 298-8225
Mailing address
2506 LARRYVALE RD, BALTIMORE, MD 21209-3206
(410) 764-1116
(410) 298-8225
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
025559
MD
Other
Enumeration date
05/12/2007
Last updated
11/20/2007
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