Basic Information
Provider Information | |||||||||
NPI: | 1437255734 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST HOSPITAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHWEST CARDIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5401 OLD COURT RD | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | RANDALLSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 211335103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106015524 | ||||||||
FaxNumber: | 4106018946 | ||||||||
Practice Location | |||||||||
Address1: | 5401 OLD COURT RD | ||||||||
Address2: |   | ||||||||
City: | RANDALLSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 211335103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105212200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 10/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORMICK | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AVP | ||||||||
AuthorizedOfficialTelephone: | 4107014618 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NORTHWEST HOSPITAL CENTER, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 03-004 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X | 03-004 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207RC0000X | 03-004 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | CN6601 | 01 | MD | R/R MEDICARE GROUP # | OTHER |