Basic Information
| Provider Information | |||||||||
| NPI: | 1982147518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATCARE GROUP II, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHOICEONE URGENT CARE II | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 FRONT AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210935300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102967190 | ||||||||
| FaxNumber: | 4439917768 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 S PHILADELPHIA BLVD | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210013602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4433452650 | ||||||||
| FaxNumber: | 4433452666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 06/16/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURGER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | THEODORE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4102967190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | H0062737 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QU0200X | H0062737 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | H0062737 | 01 | MD | MEDICAL LICENSE | OTHER |