Provider Demographics
NPI:1922008002
Name:ST. AGNES HOSPICE
Entity Type:Organization
Organization Name:ST. AGNES HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-752-8700
Mailing Address - Street 1:1501 S EDGEWOOD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1071
Mailing Address - Country:US
Mailing Address - Phone:410-368-2825
Mailing Address - Fax:410-368-8449
Practice Address - Street 1:1501 S EDGEWOOD ST
Practice Address - Street 2:SUITE A
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-1071
Practice Address - Country:US
Practice Address - Phone:410-368-2825
Practice Address - Fax:410-368-8449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH1512251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039395900Medicaid
21-1512Medicare ID - Type Unspecified