Basic Information
| Provider Information | |||||||||
| NPI: | 1811041163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHEPPARD PRATT HEALTH SYSTEM, INC. | ||||||||
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| OtherOrganizationName: | FORBUSH SCHOOL AT GLYNDON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383150 | ||||||||
| FaxNumber: | 4109383159 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | REISTERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211361854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105175400 | ||||||||
| FaxNumber: | 4105175600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CORPORATE BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4109383150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 03-64551 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 681500600 | 05 | MD | MEDICAID |