1104253160 NPI number — TOTAL IMAGE CARE, INC.

Table of content: (NPI 1104253160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104253160 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:
IMAGE RECOVERY CENTER AT UPPER CHESAPEAKE
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:
1104253160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1850 YORK RD
Provider Second Line Business Mailing Address:
SUITE I
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-5122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-560-0614
Provider Business Mailing Address Fax Number:
410-560-0613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 UPPER CHESAPEAKE DR
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21014-4324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-643-3224
Provider Business Practice Location Address Fax Number:
443-643-3227
Provider Enumeration Date:
10/03/2013

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:
410-560-0614

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 "CAREFIRST BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 6010000800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: MH24 . This is a "CAREFIRST BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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