Basic Information
| Provider Information | |||||||||
| NPI: | 1093987729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREATER BADEN MEDICAL SERVICE INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREATER BADEN MEDICAL SERVICE AT CAPITOL HEIGHTS II | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7450 ALBERT RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206133035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018882233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1442 ADDISON RD S | ||||||||
| Address2: | |||||||||
| City: | CAPITOL HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207434413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018882233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2008 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | JENKINS | ||||||||
| AuthorizedOfficialFirstName: | LOVPRIEST | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3018882233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREATER BADEN MEDICAL SERVICE INCORPORATED | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 911431900 | 05 | MD | MEDICAID |