1194174391 NPI number — STATCARE GROUP III, PC

Table of content: (NPI 1194174391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194174391 NPI number — STATCARE GROUP III, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATCARE GROUP III, PC
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:
1194174391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 FRONT AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-5300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-296-7190
Provider Business Mailing Address Fax Number:
443-991-7768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28522-C MARLBORO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-746-0086
Provider Business Practice Location Address Fax Number:
443-746-0669
Provider Enumeration Date:
06/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BURGER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
410-296-7190

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X , with the licence number:  H0062737 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: H0062737 , 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)

  • Identifier: H0062737 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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