Basic Information
| Provider Information | |||||||||
| NPI: | 1588654289 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNS HOPKINS UNIVERSITY | ||||||||
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| OtherOrganizationName: | JHU - WILMER EYE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6201 GREENLEIGH AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLE RIVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212202004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109336423 | ||||||||
| FaxNumber: | 4105004266 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 NORTH WOLFE STREET | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212640001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106145115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEATING | ||||||||
| AuthorizedOfficialFirstName: | SHAVONDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR PRODUCTION UNIT MGR | ||||||||
| AuthorizedOfficialTelephone: | 4109336430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHNS HOPKINS UNIVERSITY | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207WX0009X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0107X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0108X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0109X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0110X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0120X | N | 193200000X MULTI-SPECIALTY GROUP | 207WX0200X | N | 193200000X MULTI-SPECIALTY GROUP | 207W00000X | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CA9060 | 01 | MD | RRMC | OTHER | 769191200 | 05 | MD | MEDICAID | 010170055 | 05 | DC | MEDICAID |