Provider Demographics
NPI:1679078679
Name:LGM HEALTHCARE SERVICES & AESTHETICS MEDICINE
Entity type:Organization
Organization Name:LGM HEALTHCARE SERVICES & AESTHETICS MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITONER
Authorized Official - Prefix:MS
Authorized Official - First Name:ILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELVIN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC , NP-C
Authorized Official - Phone:410-661-9020
Mailing Address - Street 1:7850 ROSSVILLE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3934
Mailing Address - Country:US
Mailing Address - Phone:410-661-9020
Mailing Address - Fax:
Practice Address - Street 1:7850 ROSSVILLE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3934
Practice Address - Country:US
Practice Address - Phone:443-858-6828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD444289000Medicaid