Basic Information
| Provider Information | |||||||||
| NPI: | 1922152578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHEPPARD PRATT HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FORBUSH SCHOOL AT EDGAR ALLEN POE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
| FaxNumber: | 4109383159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 SHADYSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | SUITLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207464805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017022130 | ||||||||
| FaxNumber: | 3017024461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CORPORATE BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4109383150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 3960 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3960 | 01 | MD | SCHOOL LICENSE NUMBER | OTHER | 411238500 | 05 | MD | MEDICAID |