Basic Information
| Provider Information | |||||||||
| NPI: | 1972157295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MARYLAND ST. JOSEPH ORTHOPAEDICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8322 BELLONA AVE # 100 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212042065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103377900 | ||||||||
| FaxNumber: | 4107698591 | ||||||||
| Practice Location | |||||||||
| Address1: | 7505 OSLER DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212047737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103378888 | ||||||||
| FaxNumber: | 4108234833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2019 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4103371602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 4216709 | 05 | MD | MEDICAID |