Basic Information
| Provider Information | |||||||||
| NPI: | 1508826017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VA MARYLAND HEALTH CARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BALTIMORE & PERRY POINT VA MEDICAL CENTERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11 SAINT MICHAELS WAY | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212121238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103770243 | ||||||||
| FaxNumber: | 4103774387 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
| FaxNumber: | 4106057792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNOW | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OF STAFF | ||||||||
| AuthorizedOfficialTelephone: | 4106057000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD.MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | D0014337 | MD | Y | Hospitals | General Acute Care Hospital |
No ID Information.