Basic Information
Provider Information | |||||||||
NPI: | 1255424164 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHEPPARD PRATT HEALTH SYSTEM, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JEFFERSON RTC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6501 N CHARLES ST | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212046819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109383000 | ||||||||
FaxNumber: | 4109383159 | ||||||||
Practice Location | |||||||||
Address1: | 2940 POINT OF ROCKS RD. | ||||||||
Address2: |   | ||||||||
City: | JEFFERSON | ||||||||
State: | MD | ||||||||
PostalCode: | 217550009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016248400 | ||||||||
FaxNumber: | 3016248404 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 01/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KATZ | ||||||||
AuthorizedOfficialFirstName: | BONNIE | ||||||||
AuthorizedOfficialMiddleName: | B. | ||||||||
AuthorizedOfficialTitleorPosition: | VP, CORPORATE BUSINESS DEVELOPMENT | ||||||||
AuthorizedOfficialTelephone: | 4109383154 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 10-018 | MD | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
ID Information
ID | Type | State | Issuer | Description | 081505500 | 05 | MD |   | MEDICAID |