Basic Information
| Provider Information | |||||||||
| NPI: | 1427425933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATCARE GROUP LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHOICEONE URGENT CARE OF TOWSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1400 FRONT AVENUE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | 4439917768 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 MERRITT BLVD | ||||||||
| Address2: | |||||||||
| City: | DUNDALK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212223212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | 4102960344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURGER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | THEODORE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4102967190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QU0200X | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.