Basic Information
| Provider Information | |||||||||
| NPI: | 1972846830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER BALTIMORE MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 N CHARLES ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212045805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438493760 | ||||||||
| FaxNumber: | 4438498138 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 N CHARLES ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212045805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438493760 | ||||||||
| FaxNumber: | 4438498138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | HUFF | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4438492682 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | N/A | 05 | MD | MEDICAID |