Basic Information
| Provider Information | |||||||||
| NPI: | 1033573050 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH CARE FOR THE HOMELESS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTH CARE FOR THE HOMELESS WEST BALTIMORE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 FALLSWAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212024800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108375533 | ||||||||
| FaxNumber: | 4108378020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W BALTIMORE ST | ||||||||
| Address2: | SUITE 247 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212231558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437031400 | ||||||||
| FaxNumber: | 4438636661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINDAMOOD | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4108375533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 383841200 | 05 | MD | MEDICAID |