Basic Information
| Provider Information | |||||||||
| NPI: | 1447354790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST HOSPITAL CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST WOUND CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 09/08/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| 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 | 208600000X | 03-004 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CN6601 | 01 | MD | R/R MEDICARE GROUP # | OTHER |