Basic Information
| Provider Information | |||||||||
| NPI: | 1578553350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | SAMIR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12119 HAYLAND FARM WAY | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210426014 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 TWIN SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | HALETHORPE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212273553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107375000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0061832 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3763900 | 01 | MD | AETNA HMO | OTHER | 6106139 | 01 | MD | CIGNA | OTHER | 406338400 | 05 | MD | MEDICAID | 5234 | 01 | MD | BRAVO/ELDER HEALTH | OTHER | F551-0010 | 01 | DC | CARE FIRST BLUE CROSS | OTHER | 108285 | 01 | MD | JOHNS HOPKINS HEALTH CARE | OTHER | 7931659 | 01 | MD | AETNA PPO | OTHER | 64359802 | 01 | MD | CARE FIRST BLUE CROSS | OTHER |