Basic Information
| Provider Information | |||||||||
| NPI: | 1942812144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNS HOPKINS UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JHU - ADDICTION MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64264 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109336423 | ||||||||
| FaxNumber: | 4109331390 | ||||||||
| Practice Location | |||||||||
| Address1: | 5200 EASTERN AVENUE | ||||||||
| Address2: | MASON F. LORD BLDG, EAST TOWER, 2ND FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212242734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105502999 | ||||||||
| FaxNumber: | 4103672442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 03/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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 | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0300X | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 131688503 | 05 | MD | MEDICAID |