Basic Information
| Provider Information | |||||||||
| NPI: | 1205062767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SINAI HOSPITAL OF BALTIMORE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CROSSROADS INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | CREDENTIALING | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015523 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 CROSSROADS DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109989100 | ||||||||
| FaxNumber: | 4109989104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EFIRD | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4106017019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SINAI HOSPITAL OF BALTIMORE | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30-062 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 382301600 | 05 | MD | MEDICAID | C31152 | 01 | MD | R/R MEDICARE GROUP # | OTHER |