Basic Information
| Provider Information | |||||||||
| NPI: | 1275616526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | MONTA | ||||||||
| MiddleName: | LAVAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 FORBES STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102636363 | ||||||||
| FaxNumber: | 4102634086 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 FORBES STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102636363 | ||||||||
| FaxNumber: | 4102634086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD33125 | DC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | D63209 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | FC1435379 | 01 | MD | DEA | OTHER | 37492800 | 05 | DC | MEDICAID |