Provider Demographics
NPI:1568508927
Name:PHYSICIAN GROUP WPCC
Entity Type:Organization
Organization Name:PHYSICIAN GROUP WPCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ARCHIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:410-209-6201
Mailing Address - Street 1:630 W FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1543
Mailing Address - Country:US
Mailing Address - Phone:410-209-6201
Mailing Address - Fax:410-209-6209
Practice Address - Street 1:630 W FAYETTE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1543
Practice Address - Country:US
Practice Address - Phone:410-209-6201
Practice Address - Fax:410-209-6209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit