1851582027 NPI number — HEALTHWISE MEDICINE 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 1851582027 NPI number — HEALTHWISE MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHWISE MEDICINE 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:
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:
1851582027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8501 LASALLE RD
Provider Second Line Business Mailing Address:
SUITE #102
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-5914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-821-8087
Provider Business Mailing Address Fax Number:
410-821-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8501 LASALLE RD
Provider Second Line Business Practice Location Address:
SUITE #102
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21286-5914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-821-8087
Provider Business Practice Location Address Fax Number:
410-821-9001
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILEY
Authorized Official First Name:
KALVIN
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PHYSICIAN CEO
Authorized Official Telephone Number:
410-821-8087

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  M49995 , 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: J203 . This is a "GHMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: J2030000 . This is a "BCBS FEDERAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 6813038 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6902000000KFD6 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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