Provider Demographics
NPI:1679134316
Name:SOUTH BALTIMORE C.A.P. INC.
Entity Type:Organization
Organization Name:SOUTH BALTIMORE C.A.P. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:MHS CSC-AD
Authorized Official - Phone:410-752-2475
Mailing Address - Street 1:1435 S HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4438
Mailing Address - Country:US
Mailing Address - Phone:410-752-2475
Mailing Address - Fax:410-752-4772
Practice Address - Street 1:7 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-4429
Practice Address - Country:US
Practice Address - Phone:410-385-1466
Practice Address - Fax:410-752-4772
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH BALTIMORE C.A.P. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1083949895Medicaid