1073754461 NPI number — BALTIMORE MEDICAL SYSTEM INC

Table of content: (NPI 1073754461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073754461 NPI number — BALTIMORE MEDICAL SYSTEM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALTIMORE MEDICAL SYSTEM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BALTIMORE MEDICAL SYSTEM INC PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073754461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/13/2023
NPI Reactivation Date:
06/01/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5525 EASTERN AVE STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21224-2796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-703-3654
Provider Business Mailing Address Fax Number:
443-703-3639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 ERDMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21213-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-703-3683
Provider Business Practice Location Address Fax Number:
410-534-0143
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY SERVICES
Authorized Official Telephone Number:
443-703-3654

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: P04992 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 416605100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2119406 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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