Provider Demographics
NPI:1093724163
Name:PLUMTREE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:PLUMTREE PEDIATRICS, LLC
Other - Org Name:LAUREL PEDIATRIC AND TEEN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GENEROSA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:LAZOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-569-9533
Mailing Address - Street 1:2014 S TOLLGATE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-5903
Mailing Address - Country:US
Mailing Address - Phone:410-569-9533
Mailing Address - Fax:410-569-1254
Practice Address - Street 1:2014 S TOLLGATE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5903
Practice Address - Country:US
Practice Address - Phone:410-569-9533
Practice Address - Fax:410-569-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-06
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD34413261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD293901100Medicaid
MD408959600Medicaid
MDE16785Medicare UPIN