1558726141 NPI number — STATCARE GROUP II, PC

Table of content: (NPI 1558726141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558726141 NPI number — STATCARE GROUP II, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATCARE GROUP II, 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:
1558726141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2020
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:
410-296-0344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2315 BEL AIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLSTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21047-2740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-296-7190
Provider Business Practice Location Address Fax Number:
410-296-0344
Provider Enumeration Date:
12/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
ANGELA
Authorized Official Title or Position:
CREDENTIALING & PROVIDER ENROLLMENT
Authorized Official Telephone Number:
410-296-7190

Provider Taxonomy Codes

  • 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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