1134209828 NPI number — MARYLAND CENTER FOR INTEGRATIVE MEDICINE

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 1134209828 NPI number — MARYLAND CENTER FOR INTEGRATIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND CENTER FOR INTEGRATIVE MEDICINE
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:
1134209828
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:
658 KENILWORTH DR STE 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21204-2334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-828-3585
Provider Business Mailing Address Fax Number:
410-828-8674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
658 KENILWORTH DR STE 206
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:
21204-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-828-3585
Provider Business Practice Location Address Fax Number:
410-828-8674
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
SHERYL
Authorized Official Middle Name:
BAKER
Authorized Official Title or Position:
CEO, CLINICAL DIRECTOR
Authorized Official Telephone Number:
410-969-0981

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  U00452 , 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)





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