Basic Information
| Provider Information | |||||||||
| NPI: | 1457642274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHEPPARD PRATT HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE FORBUSH SCHOOL AT GLYNDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | REISTERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211361854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105175400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 407 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | REISTERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211361854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105175400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP BUSINESS DEV AND SUPPORT OPS | ||||||||
| AuthorizedOfficialTelephone: | 4109383154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 03-64551 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 214000 | 01 | MD | MEDICARE | OTHER | 227401900 | 05 | MD | MEDICAID |