Provider Demographics
NPI:1346270428
Name:BALTIMORE AMBULATORY CENTER FOR ENDOSCOPY
Entity Type:Organization
Organization Name:BALTIMORE AMBULATORY CENTER FOR ENDOSCOPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAHANGIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-574-7776
Mailing Address - Street 1:19 FONTANA LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3047
Mailing Address - Country:US
Mailing Address - Phone:410-574-7776
Mailing Address - Fax:410-574-9038
Practice Address - Street 1:19 FONTANA LN
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3047
Practice Address - Country:US
Practice Address - Phone:410-574-7776
Practice Address - Fax:410-574-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1159261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD136520700Medicaid
MD136520700Medicaid