Basic Information
| Provider Information | |||||||||
| NPI: | 1710071725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALTIMORE WASHINGTON PROFESSIONAL SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE AIELLO BREAST CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 203 HOSPITAL DR | ||||||||
| Address2: | SUITE B100 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210616904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538351 | ||||||||
| FaxNumber: | 4105538352 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 HOSPITAL DR | ||||||||
| Address2: | SUITE B100 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210616904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538351 | ||||||||
| FaxNumber: | 4105538352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAYO | ||||||||
| AuthorizedOfficialFirstName: | CHARLENE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4105538353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BALTIMORE WASHINGTON MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1622878 | 01 | MD | UNITED HEALTHCARE PROVIDE | OTHER | 2131125 | 01 | MD | MAMSI PROVIDER NUMBER | OTHER | 3767375 | 01 | MD | AETNA HMO PROVIDER NUMBER | OTHER | 406923400 | 05 | MD | MEDICAID | 33525 | 01 | MD | JOHN HOPKINS HEALTH CARE | OTHER | 1303080 | 01 | MD | CIGNA PROVIDER NUMBER | OTHER | 704197 | 01 | MD | NCPPO PROVIDER NUMBER | OTHER | DD8312 | 01 | MD | MEDICARE RAILROAD | OTHER | J6860006 | 01 | MH | CAREFIRST BCBS OF DC PROV | OTHER | 5353197 | 01 | MH | AETNA PPO PROVIDER NUMBER | OTHER | 645177-01 | 01 | MD | CAREFIRST BCBS OF MD PROV | OTHER | 9002247 | 01 | MD | PRIVATE HEALTHCARE SYSTEM | OTHER |