Provider Demographics
NPI:1457642274
Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Other - Org Name:THE FORBUSH SCHOOL AT GLYNDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP BUSINESS DEV AND SUPPORT OPS
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-938-3154
Mailing Address - Street 1:407 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1854
Mailing Address - Country:US
Mailing Address - Phone:410-517-5400
Mailing Address - Fax:
Practice Address - Street 1:407 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1854
Practice Address - Country:US
Practice Address - Phone:410-517-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03-64551261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD214000OtherMEDICARE
MD227401900Medicaid