Basic Information
| Provider Information | |||||||||
| NPI: | 1336211929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNS HOPKINS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HOPKINS ELDER PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4940 EASTERN AVE | ||||||||
| Address2: | MFL BLDG, 1ST FLOOR, EAST | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212242735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439970001 | ||||||||
| FaxNumber: | 4439970011 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 EASTERN AVE | ||||||||
| Address2: | MFL BLDG, FIRST FLOOR, EAST | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212242735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105507044 | ||||||||
| FaxNumber: | 4105507045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WERTHMAN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE, TREASURER, CFO, JHHS | ||||||||
| AuthorizedOfficialTelephone: | 4109556552 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | Y | Agencies | PACE Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 409642800 | 05 | MD | MEDICAID | 409639800 | 05 | MD | MEDICAID |