Basic Information
Provider Information | |||||||||
NPI: | 1023505666 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED CATHOLIC CHARITIES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLA MARIA SUD- DUNDALK LEVEL 1 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 DULANEY VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | TIMONIUM | ||||||||
State: | MD | ||||||||
PostalCode: | 210932739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6676002249 | ||||||||
FaxNumber: | 6676004068 | ||||||||
Practice Location | |||||||||
Address1: | 2 N DUNDALK AVE | ||||||||
Address2: |   | ||||||||
City: | DUNDALK | ||||||||
State: | MD | ||||||||
PostalCode: | 212224221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6676003681 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2018 | ||||||||
LastUpdateDate: | 01/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OVERSMITH | ||||||||
AuthorizedOfficialFirstName: | GLORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6676002249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   | MD | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.