Provider Demographics
NPI:1073754461
Name:BALTIMORE MEDICAL SYSTEM INC
Entity Type:Organization
Organization Name:BALTIMORE MEDICAL SYSTEM INC
Other - Org Name:BALTIMORE MEDICAL SYSTEM INC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-703-3654
Mailing Address - Street 1:5525 EASTERN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2796
Mailing Address - Country:US
Mailing Address - Phone:443-703-3654
Mailing Address - Fax:443-703-3639
Practice Address - Street 1:3120 ERDMAN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1720
Practice Address - Country:US
Practice Address - Phone:443-703-3683
Practice Address - Fax:410-534-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2023-12-08
Deactivation Date:2023-05-13
Deactivation Code:
Reactivation Date:2023-06-01
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
MDP049923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416605100Medicaid
2119406OtherPK