1679134316 NPI number — SOUTH BALTIMORE C.A.P. INC.

Table of content: (NPI 1679134316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679134316 NPI number — SOUTH BALTIMORE C.A.P. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BALTIMORE C.A.P. 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:
1679134316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1435 S HANOVER 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:
21230-4438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-752-2475
Provider Business Mailing Address Fax Number:
410-752-4772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 W RANDALL ST
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:
21230-4429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-385-1466
Provider Business Practice Location Address Fax Number:
410-752-4772
Provider Enumeration Date:
06/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MCCREARY
Authorized Official First Name:
MELODY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
410-752-2475

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083949895 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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