Basic Information
Provider Information | |||||||||
NPI: | 1053380576 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ANNE ARUNDEL MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AAMC-PEDIATRIC HOSPITALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 64262 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212644262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434816576 | ||||||||
FaxNumber: | 4434816515 | ||||||||
Practice Location | |||||||||
Address1: | 2001 MEDICAL PKWY | ||||||||
Address2: |   | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214013280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434811000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2006 | ||||||||
LastUpdateDate: | 08/04/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLARKE | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VP BUSINESS DEVELOPMENT | ||||||||
AuthorizedOfficialTelephone: | 4434816558 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 805221 | 01 |   | JHHC | OTHER | F125 | 01 |   | CAREFIRST BCBS DC | OTHER | 507000702 | 05 | MD |   | MEDICAID | LU71AN | 01 |   | CAREFIRST BCBS MD | OTHER |