Basic Information
| Provider Information | |||||||||
| NPI: | 1881156719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRENDERGAST | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5435 SIMPKINS CT | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210436579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473703716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106019000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | D0094757 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.