1558620708 NPI number — BALTIMORE COMMUNITY RESOURCE CENTER, INC

Table of content: (NPI 1558620708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558620708 NPI number — BALTIMORE COMMUNITY RESOURCE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALTIMORE COMMUNITY RESOURCE CENTER, 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:
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:
1558620708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 W 25TH ST
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:
21218-5003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-366-1717
Provider Business Mailing Address Fax Number:
410-889-4167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3623 PARKDALE 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:
21211-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-366-1717
Provider Business Practice Location Address Fax Number:
410-889-4167
Provider Enumeration Date:
05/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WOODELL
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
410-366-1717

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  903995 , 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: 417128400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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