Provider Demographics
NPI:1336515519
Name:UNIVERSITY OF MARYLAND BALTIMORE
Entity Type:Organization
Organization Name:UNIVERSITY OF MARYLAND BALTIMORE
Other - Org Name:GOVERNOR'S WELLMOBILE PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ANTOL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RN
Authorized Official - Phone:410-706-5395
Mailing Address - Street 1:655 W LOMBARD ST
Mailing Address - Street 2:SUITE 425B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1512
Mailing Address - Country:US
Mailing Address - Phone:410-706-5395
Mailing Address - Fax:410-706-0140
Practice Address - Street 1:8011 NEW HAMPSHIRE AVE
Practice Address - Street 2:MOBILE UNIT
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-4612
Practice Address - Country:US
Practice Address - Phone:866-228-9668
Practice Address - Fax:410-706-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care