1063942563 NPI number — CONCERTED CARE GROUP MANAGEMENT LLC

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 1063942563 NPI number — CONCERTED CARE GROUP MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONCERTED CARE GROUP MANAGEMENT LLC
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:
6
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:
1063942563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
428 E 25TH ST
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:
21218-5304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-617-0142
Provider Business Mailing Address Fax Number:
443-873-6975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 E LORRAINE 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:
21218-4712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-617-0142
Provider Business Practice Location Address Fax Number:
443-873-6975
Provider Enumeration Date:
06/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WAHL
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
667-239-3205

Provider Taxonomy Codes

  • Taxonomy code: 177F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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