Basic Information
| Provider Information | |||||||||
| NPI: | 1689650780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEAD | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10778 | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209140778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013842338 | ||||||||
| FaxNumber: | 3013842338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 MERCANTILE LN | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018162424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 05/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD32976 | DC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 56892 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0101053834 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | D0036396 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 024557900 | 05 | DC | MEDICAID | 44330020 | 01 | DC | BLUECROSS BLUESHIELD | OTHER |