1245274901 NPI number — ST. AGNES HEALTHCARE, INC.

Table of content: (NPI 1245274901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245274901 NPI number — ST. AGNES HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. AGNES HEALTHCARE, 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:
1245274901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3585 WASHINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALETHORPE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21227-1676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
667-234-2126
Provider Business Mailing Address Fax Number:
667-234-2947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 CATON AVE
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:
21229-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-234-2126
Provider Business Practice Location Address Fax Number:
667-238-2947
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANDER KOLK
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
667-234-2101

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 282N00000X , 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: 000115500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016860700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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