Provider Demographics
NPI:1518011659
Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Other - Org Name:JEFFERSON SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CORPORATE BUSINESS DEVELOPMENT
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:410-938-3150
Mailing Address - Street 1:6501 NORTH CHARLES STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6819
Mailing Address - Country:US
Mailing Address - Phone:410-938-3000
Mailing Address - Fax:410-938-3159
Practice Address - Street 1:2940 POINT OF ROCKS ROAD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:MD
Practice Address - Zip Code:21755-0009
Practice Address - Country:US
Practice Address - Phone:301-629-8400
Practice Address - Fax:301-629-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3801261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD201901900Medicaid
MD214000Medicare PIN