Provider Demographics
NPI:1467999334
Name:MAYOR AND CITY COUNCIL OF BALTIMORE
Entity Type:Organization
Organization Name:MAYOR AND CITY COUNCIL OF BALTIMORE
Other - Org Name:STI/PREP/EII/CHARM CLINIC-DRUID
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING & REVENUE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:ALONZO
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-739-3253
Mailing Address - Street 1:1001 E FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4715
Mailing Address - Country:US
Mailing Address - Phone:410-396-0176
Mailing Address - Fax:410-396-7897
Practice Address - Street 1:1515 W NORTH AVE FL 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1735
Practice Address - Country:US
Practice Address - Phone:410-396-0176
Practice Address - Fax:410-396-7897
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYOR AND CITY COUNCIL OF BALTIMORE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-30
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1780781591251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420845500Medicaid