Provider Demographics
NPI:1679512909
Name:SHOCK TRAUMA ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:SHOCK TRAUMA ASSOCIATES, P.A.
Other - Org Name:SHOCK TRAUMA ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROFESSIONAL FEES
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:667-214-1334
Mailing Address - Street 1:PO BOX 64793
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4793
Mailing Address - Country:US
Mailing Address - Phone:410-328-6704
Mailing Address - Fax:410-328-4214
Practice Address - Street 1:11 S PACA ST
Practice Address - Street 2:SUITE 500
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1791
Practice Address - Country:US
Practice Address - Phone:410-328-6704
Practice Address - Fax:410-328-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH749Medicare ID - Type Unspecified
MDCD7536Medicare PIN