Basic Information
| Provider Information | |||||||||
| NPI: | 1366526535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA MEDICAL CENTER-BALTIMORE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | ANTONETTE | ||||||||
| AuthorizedOfficialMiddleName: | ROMERO | ||||||||
| AuthorizedOfficialTitleorPosition: | CRNP | ||||||||
| AuthorizedOfficialTelephone: | 4106057000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | R146458 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
ID Information
| ID | Type | State | Issuer | Description | VAD000 | 01 | MD | VAMHCS UPIN | OTHER |