Basic Information
Provider Information | |||||||||
NPI: | 1982950846 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF MARYLAND ST. JOSEPH ORTHOPAEDICS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TOWSON ORTHOPAEDIC ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7601 OSLER DR | ||||||||
Address2: |   | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212047700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8322 BELLONA AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TOWSON | ||||||||
State: | MD | ||||||||
PostalCode: | 212042065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103377900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2012 | ||||||||
LastUpdateDate: | 04/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NICHOLSON | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4103371000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.