Basic Information
| Provider Information | |||||||||
| NPI: | 1730292053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE JOHNS HOPKINS HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JOHNS HOPKINS AT GREENSPRING LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 632049 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212632049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109331306 | ||||||||
| FaxNumber: | 4109331509 | ||||||||
| Practice Location | |||||||||
| Address1: | 10755 FALLS ROAD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105832679 | ||||||||
| FaxNumber: | 4105832681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | REDONDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, TREASURER,CFO,JHHS | ||||||||
| AuthorizedOfficialTelephone: | 4109550620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHNS HOPKINS HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 728 | MD | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 325408900 | 05 | MD | MEDICAID |