Provider Demographics
NPI:1295040756
Name:BALTIMORE WASHINGTON PROFESSIONAL SERVICES INC
Entity Type:Organization
Organization Name:BALTIMORE WASHINGTON PROFESSIONAL SERVICES INC
Other - Org Name:BWMC SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAESCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-787-4879
Mailing Address - Street 1:PO BOX 62544
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 HOSPITAL DR
Practice Address - Street 2:SUITE 303
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5805
Practice Address - Country:US
Practice Address - Phone:410-553-8290
Practice Address - Fax:410-553-8288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCPD3BWOtherCAREFIRST BLUE CROSS BLUE SHIELD
W763OtherCARE FIRST BLUE CROSS BLUE SHIELD