Provider Demographics
NPI:1508295726
Name:ABSOLUTECARE OF BALTIMORE, LLC
Entity Type:Organization
Organization Name:ABSOLUTECARE OF BALTIMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRENTLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:443-738-0281
Mailing Address - Street 1:1040 PARK AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5633
Mailing Address - Country:US
Mailing Address - Phone:443-738-0300
Mailing Address - Fax:404-231-5677
Practice Address - Street 1:1040 PARK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:443-738-0300
Practice Address - Fax:443-738-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0071154207Q00000X
MDD53063207R00000X
261QP2300X
MDR167803363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD780015101Medicaid
MD01938969OtherAMERIGROUP MCO
MD780015100Medicaid