Basic Information
| Provider Information | |||||||||
| NPI: | 1942278882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANNE ARUNDEL MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BREAST CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64720 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816573 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 MEDICAL PKWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434815300 | ||||||||
| FaxNumber: | 4434816705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 08/04/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4434816558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 507000706 | 05 | MD | MEDICAID | 5886 | 01 | CAREFIRST | OTHER | 9226077 | 01 | AETNA HMO | OTHER | K313BR | 01 | CAREFIRST | OTHER | FG3HBR | 01 | CAREFIRST MD | OTHER | 1617552 | 01 | AETNA PPO | OTHER |