Provider Demographics
NPI:1043864002
Name:UNIVERSITY OF MARYLAND ST. JOSEPH ORTHOPAEDICS, LLC
Entity Type:Organization
Organization Name:UNIVERSITY OF MARYLAND ST. JOSEPH ORTHOPAEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-337-1602
Mailing Address - Street 1:8322 BELLONA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2065
Mailing Address - Country:US
Mailing Address - Phone:410-337-7900
Mailing Address - Fax:410-769-8591
Practice Address - Street 1:9110 PHILADELPHIA RD STE 308
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4327
Practice Address - Country:US
Practice Address - Phone:410-337-7900
Practice Address - Fax:410-391-8084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF MARYLAND ST. JOSEPH ORTHOPAEDICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4216709Medicaid