Basic Information
| Provider Information | |||||||||
| NPI: | 1679868848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDICS AT BON SECOURS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6934 AVIATION BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210612593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4439490814 | ||||||||
| FaxNumber: | 4439490825 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W BALTIMORE ST | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212231558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103623000 | ||||||||
| FaxNumber: | 4103623010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | STEWART | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4439490814 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.