Basic Information
| Provider Information | |||||||||
| NPI: | 1912240342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONWAY | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | JOHNSON | ||||||||
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| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9910 FRANKLIN SQUARE DR | ||||||||
| Address2: | 2110 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212364902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109336423 | ||||||||
| FaxNumber: | 4109331390 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 N WOLFE ST | ||||||||
| Address2: | NELSON 215 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105022128 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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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 | 207R00000X | D81162 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 109494700 | 05 | MD | MEDICAID |