1053681130 NPI number — BALTIMORE COUNTY MARYLAND

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 1053681130 NPI number — BALTIMORE COUNTY MARYLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALTIMORE COUNTY MARYLAND
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:
DEPT. OF HEALTH-DUNDALK ELEMENTARY WELLNESS CENTER
Provider Other Organization Name Type Code:
5
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:
1053681130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6401 YORK RD
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21212-2152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-887-2077
Provider Business Mailing Address Fax Number:
410-377-9646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 PLAYFIELD ST
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:
21222-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-887-4130
Provider Business Practice Location Address Fax Number:
410-666-8748
Provider Enumeration Date:
01/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRIVACY OFFICER
Authorized Official Telephone Number:
410-887-2077

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 420953200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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