Basic Information
| Provider Information | |||||||||
| NPI: | 1821277856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALTIMORE WASHINGTON PROFESSIONAL SERVICES INC. | ||||||||
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| OtherOrganizationName: | BWMC SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64584 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644584 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107874594 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | NOEL | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4107874594 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RH0003X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | Q818 | 01 | MD | BLUE CROSS BLUE SHIELD | OTHER | ZEZT | 01 | MD | MEDICARE GROUP | OTHER | DB3GBW | 01 | MD | BLUE CROSS BLUE SHIELD | OTHER | 165767 | 01 | MD | MEDICARE PTAN | OTHER |