Provider Demographics
NPI:1184026478
Name:UMMC MIDTOWN CAMPUS
Entity Type:Organization
Organization Name:UMMC MIDTOWN CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:CVACH
Authorized Official - Suffix:
Authorized Official - Credentials:RRT,CPFT
Authorized Official - Phone:410-225-8016
Mailing Address - Street 1:827 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4606
Mailing Address - Country:US
Mailing Address - Phone:410-225-8010
Mailing Address - Fax:410-462-6093
Practice Address - Street 1:827 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4606
Practice Address - Country:US
Practice Address - Phone:410-225-8010
Practice Address - Fax:410-462-6093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1057291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1669565180Medicaid