MBP PA Collaboration Agreement

MARYLAND BOARD OF PHYSICIANS

Collaboration Agreement Receipt of Completion

PA License Number: C0001911 MARY BETH LENNOX MENDOZA

Collaboration Agreement No:

5611

Submit Date:

6/22/2025

Confirmation No:

5611_2386C0001911

Section 1 - Physician Assistant Information
Confidential Information redacted.

Section 2 - Primary Practice Setting & Location:

Practice Type:

Private Practice / Outpatient Clinic

Facility

Chesapeake Urology Associates

Address

1838 Greene Tree Rd
Pikesville MD 21208

County

Non-Maryland

Includes Telehealth?

Is this the location where a copy of your collaboration agreement is on file? NO
A copy (paper or electronic) must be immediately available upon request by the Board.

Location: 10200 Grand Central Avenue, Suite 220, Owings Mills, MD 21117

Section 3 - Advanced Duties and Prescriptive and Dispensing Authority
1.Does this Collaboration Agreement include Advanced Duties? YES

1a. Advanced Duties: Please select the best option.
I attest that I:

have 7,000 hours OR;

work at an exempt location OR;

have a Board-approved advanced duty addendum on file or;

am training on advanced duties and will submit an advanced duty addendum to the Board for approval in the future.

Note: (Exempt locations include hospitals, ambulatory surgical facilites, FQHC, or another practice setting listed on a hospital delineation of privileges.)

2. Does this Collaboration Agreement include prescriptive authority? YES

3. Does this Collaboration Agreement include dispensing authority under a physician's active dispensing permit? YES

Physician's Name: Dr. Keith O'Reilly | License No: D0064335

Maryland Board of Physicians 4201 Patterson Avenue Baltimore, MD 21215 410.764.4777 | Toll Free 800.492.6836