Provider Demographics
NPI:1679517544
Name:MISHNER, EDWARD BARRY (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:BARRY
Last Name:MISHNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7253 AMBASSADOR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2710
Mailing Address - Country:US
Mailing Address - Phone:443-436-1116
Mailing Address - Fax:443-436-1256
Practice Address - Street 1:7253 AMBASSADOR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2710
Practice Address - Country:US
Practice Address - Phone:443-436-1116
Practice Address - Fax:443-436-1256
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00210792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD317841200Medicaid
B94373Medicare UPIN
MD300105798Medicare PIN
MD527L605CMedicare PIN
MD731LI711Medicare PIN
P00133768Medicare PIN
MD301L89AAMedicare PIN
MD300076146Medicare PIN