Basic Information
| Provider Information | |||||||||
| NPI: | 1316466881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATCARE GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHOICEONE URGENT CARE OF TOWSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 FRONT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210935364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | 4439917768 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 W 40TH ST STE 173 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURGER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | THEODORE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 4102967190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATCARE GROUP, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.