Basic Information
| Provider Information | |||||||||
| NPI: | 1932269495 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHEPPARD PRATT HEALTH SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHEPPARD PRATT - BALTIMORE/WASHINGTON CAMPUS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 7220 DISCOVERY DRIVE | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | SCANLAN | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PATIENT FISCAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4109385046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHEPPARD PRATT HEALTH SYSTEM, INC | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 13-002 | MD | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 165800002 | 05 | MD | MEDICAID |