Provider Demographics
NPI:1639231541
Name:JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Entity Type:Organization
Organization Name:JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Other - Org Name:COMMUNITY PSYCHIATRY - OFF SITE SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:VP, FINANCE, TREASURER, CFO, JHHS
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WERTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-955-6552
Mailing Address - Street 1:PO BOX 632053
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-0001
Mailing Address - Country:US
Mailing Address - Phone:443-997-0001
Mailing Address - Fax:443-997-0011
Practice Address - Street 1:1821 PORTAL STREET
Practice Address - Street 2:SUITE B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-6518
Practice Address - Country:US
Practice Address - Phone:410-550-0070
Practice Address - Fax:410-550-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30005261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
58853110OtherMA CONTRACTOR
MD341475200Medicaid
046611500OtherMA CONTRACTOR