Provider Demographics
NPI:1245385434
Name:BALTIMORE COUNTY DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:BALTIMORE COUNTY DEPARTMENT OF HEALTH
Other - Org Name:EASTERN REGIONAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-887-2077
Mailing Address - Street 1:6401 YORK RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2152
Mailing Address - Country:US
Mailing Address - Phone:410-887-3740
Mailing Address - Fax:410-377-4751
Practice Address - Street 1:9100 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3903
Practice Address - Country:US
Practice Address - Phone:410-887-3740
Practice Address - Fax:410-377-4751
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BALTIMORE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD702741900Medicaid
MD025FMedicare PIN