Basic Information
| Provider Information | |||||||||
| NPI: | 1912407222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MARYLAND COMMUNITY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ELKRIDGE LANDING RD FL 2 | ||||||||
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| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434625010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107874000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2018 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | KAYLEN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4107638787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.