Basic Information
| Provider Information | |||||||||
| NPI: | 1164405866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAGOC | ||||||||
| FirstName: | ANNE MARIE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62063 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212642063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107065181 | ||||||||
| FaxNumber: | 4107065103 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 W LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286335 | ||||||||
| FaxNumber: | 4103286136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101235704 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | D76390 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 207PP0204X | 14881 | NV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010116520 | 05 | VA | MEDICAID |