Provider Demographics
NPI:1326351206
Name:ST. PAUL PLACE SPECIALISTS, INC.
Entity Type:Organization
Organization Name:ST. PAUL PLACE SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-659-2802
Mailing Address - Street 1:PO BOX 824173
Mailing Address - Street 2:
Mailing Address - City:PHILADEPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 ST. PAUL PLACE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKT 93OtherBC/BS OF MD
MD9754OtherBLUE CHOICE
MD165 LOtherMEDICARE ID-TYPE UNSPECIFIED