Basic Information
| Provider Information | |||||||||
| NPI: | 1114346731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA MARYLAND HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2154 WINTERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928331250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148833733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 04/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF PODIATRY | ||||||||
| AuthorizedOfficialTelephone: | 4106057242 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Podiatric |
No ID Information.