Provider Demographics
NPI:1164725891
Name:MADONNA HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:MADONNA HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NKEM
Authorized Official - Middle Name:
Authorized Official - Last Name:EGUDIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-233-4039
Mailing Address - Street 1:2300 GARRISON BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2377
Mailing Address - Country:US
Mailing Address - Phone:410-233-4039
Mailing Address - Fax:410-233-4052
Practice Address - Street 1:2300 GARRISON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2377
Practice Address - Country:US
Practice Address - Phone:410-233-4039
Practice Address - Fax:410-233-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4793251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420235000Medicaid