Basic Information
Provider Information | |||||||||
NPI: | 1043305832 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PULMONARY AND CRITICAL CARE ASSOCIATES OF BALTIMORE, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 501 FAIRMOUNT AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212865457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104947920 | ||||||||
FaxNumber: | 4109028247 | ||||||||
Practice Location | |||||||||
Address1: | 501 FAIRMOUNT AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212865457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104947920 | ||||||||
FaxNumber: | 4109028247 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEST | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4104947921 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207RC0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | CC2968 | 01 |   | RAILROAD MEDICARE | OTHER | 420A | 01 | MD | BLUE SHIELD | OTHER | E554 | 01 | MD | BLUE CHOICE/FEP | OTHER | 0577133 | 01 |   | AETNA | OTHER | 415836900 | 05 | MD |   | MEDICAID |