1982147518 NPI number — STATCARE GROUP II, PC

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 1982147518 NPI number — STATCARE GROUP II, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATCARE GROUP II, PC
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:
CHOICEONE URGENT CARE II
Provider Other Organization Name Type Code:
3
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:
1982147518
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:
1400 FRONT AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-5300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-296-7190
Provider Business Mailing Address Fax Number:
443-991-7768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
744 S PHILADELPHIA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21001-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-345-2650
Provider Business Practice Location Address Fax Number:
443-345-2666
Provider Enumeration Date:
11/30/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BURGER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
THEODORE
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
410-296-7190

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X , with the licence number:  H0062737 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: H0062737 , 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: H0062737 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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