Basic Information
| Provider Information | |||||||||
| NPI: | 1497760276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64888 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008894939 | ||||||||
| FaxNumber: | 3016311002 | ||||||||
| Practice Location | |||||||||
| Address1: | 4538 EDMONDSON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212291506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103281700 | ||||||||
| FaxNumber: | 4103621748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | SIEGEL | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4103281700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 482300100 | 05 | MD | MEDICAID |