1053373472 NPI number — VA MARYLAND HEALTH CARE SYSTEM

Table of content: (NPI 1053373472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053373472 NPI number — VA MARYLAND HEALTH CARE SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VA MARYLAND HEALTH CARE SYSTEM
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:
1053373472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 TEMFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-1652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-296-2526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 N GREENE ST
Provider Second Line Business Practice Location Address:
VAMHCS
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-642-2411
Provider Business Practice Location Address Fax Number:
410-642-1867
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FONTENOT
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SUPERVISOR MSO
Authorized Official Telephone Number:
410-605-7347

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  D48215 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 282N00000X , with the licence number: 32512 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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