Basic Information
| Provider Information | |||||||||
| NPI: | 1760934186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNS HOPKINS UNIVERSITY | ||||||||
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| OtherOrganizationName: | JHU - SURGERY/PODIATRIST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64563 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644563 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 N WOLFE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109555000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Sports Medicine | 213ES0103X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0131X | 520595510 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 809803400 | 05 | MD | MEDICAID |