1720288541 NPI number — TANORAH ST. JOHN

Table of content: TANORAH ST. JOHN (NPI 1720288541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720288541 NPI number — TANORAH ST. JOHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. JOHN
Provider First Name:
TANORAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1720288541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2911 E NORTHERN PKWY
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:
21214-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2911 E NORTHERN PKWY
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:
21214-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-718-8869
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  12896 , 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: N1650001 . This is a "CAREFIRST BLUECROSS BLUES" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 64877701 . This is a "CAREFIRST BLUECROSS BLUES" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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