1073526711 NPI number — TOTAL IMAGE CARE INC

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 1073526711 NPI number — TOTAL IMAGE CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL IMAGE CARE INC
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:
6
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:
1073526711
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:
800 ARMY ROAD
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:
21204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-342-9484
Provider Business Mailing Address Fax Number:
410-342-9486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 W BELVEDERE AVE
Provider Second Line Business Practice Location Address:
IMAGE RECOVERY CENTER AT SINAI HOSPITAL
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-601-4725
Provider Business Practice Location Address Fax Number:
440-601-4609
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
410-342-9484

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F807 . This is a "BLUE CROSS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: MH24 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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