Basic Information
| Provider Information | |||||||||
| NPI: | 1629210166 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY CARE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64888 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103282273 | ||||||||
| FaxNumber: | 3016311002 | ||||||||
| Practice Location | |||||||||
| Address1: | 4538 EDMONDSON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212291506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103282273 | ||||||||
| FaxNumber: | 3016311002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | TRENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4103281184 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 400506600 | 05 | MD | MEDICAID |