Basic Information
| Provider Information | |||||||||
| NPI: | 1942373964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREATER BALTIMORE MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | GBMC, INC.-INFECTIOUS DISEASE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 631568 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212631568 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10085 RED RUN BLVD | ||||||||
| Address2: | STE 306 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211174836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105817804 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | MELCHIOR | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRES & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4438492519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREATER BALTIMORE MEDICAL CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | S121 | 01 | MD | CAREFIRST REGIONAL | OTHER | KJ68ME | 01 | MD | CAREFIRST MARYLAND | OTHER |