1457773160 NPI number — NEW GENESIS CONSULTING SERVICES

Table of content: (NPI 1457773160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457773160 NPI number — NEW GENESIS CONSULTING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW GENESIS CONSULTING SERVICES
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:
1457773160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 W PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BEL AIR
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21014-3669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-838-8331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8227 CLOVERLEAF DR STE 303
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
MILLERSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21108-1536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-987-1036
Provider Business Practice Location Address Fax Number:
888-224-0984
Provider Enumeration Date:
01/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
SYRETTA
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER OPERATOR/CLINICAL DIRECTOR
Authorized Official Telephone Number:
410-987-1036

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  04935 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 07685 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 331149000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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