1184817702 NPI number — WELLSPRING CARDIAC CARE, P.A.

Table of content: (NPI 1184817702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184817702 NPI number — WELLSPRING CARDIAC CARE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPRING CARDIAC CARE, P.A.
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:
Provider Other Organization Name Type Code:
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:
1184817702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10845 PHILADELPHIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE MARSH
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21162-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-335-0008
Provider Business Mailing Address Fax Number:
410-335-1133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 WEST RD
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE 201
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-307-1090
Provider Business Practice Location Address Fax Number:
410-307-1095
Provider Enumeration Date:
08/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SECADA-LOVIO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-307-1090

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  D0022633 , 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: 414997100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: FKJ0JC . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DN2575 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: J046 . This is a "CAREFIRST DC" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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