Provider Demographics
NPI:1104036300
Name:MARYLAND GROUP FACULTY PRACTICE LLC
Entity Type:Organization
Organization Name:MARYLAND GROUP FACULTY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-598-8700
Mailing Address - Street 1:419 W REDWOOD ST
Mailing Address - Street 2:SUITE 570
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1734
Mailing Address - Country:US
Mailing Address - Phone:410-328-6106
Mailing Address - Fax:410-328-1130
Practice Address - Street 1:419 W REDWOOD ST
Practice Address - Street 2:SUITE 570
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1734
Practice Address - Country:US
Practice Address - Phone:410-328-6106
Practice Address - Fax:410-328-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD601LMedicare UPIN