Basic Information
| Provider Information | |||||||||
| NPI: | 1427720481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHOCK TRAUMA ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64793 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103286704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | COLLIC | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 6672141334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.