Provider Demographics
NPI:1629247051
Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Other - Org Name:FORBUSH SCHOOL AT OAKMONT UPPER DIVISION
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 1:610 E DIAMOND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-5332
Mailing Address - Country:US
Mailing Address - Phone:301-330-4359
Mailing Address - Fax:301-330-0533
Practice Address - Street 1:610 E DIAMOND AVE STE E
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-5332
Practice Address - Country:US
Practice Address - Phone:301-330-4359
Practice Address - Fax:301-330-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPENDING261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414128800Medicaid
MDNUMBER PENDINGOtherST BOARD OF EDUCATION
MD214000Medicare PIN