1437450004 NPI number — EMERSON WALDEN JR, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437450004 NPI number — EMERSON WALDEN JR, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERSON WALDEN JR, 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:
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:
1437450004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9991 VILLAGE GREEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21163-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-802-6184
Provider Business Mailing Address Fax Number:
410-783-8793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 SAINT PAUL PL
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21202-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-528-1326
Provider Business Practice Location Address Fax Number:
410-783-8793
Provider Enumeration Date:
11/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WALDEN
Authorized Official First Name:
EMERSON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-802-6184

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  D17154 , 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: 118411300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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