Provider Demographics
NPI:1457606196
Name:BON SECOURS BALTIMORE PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:BON SECOURS BALTIMORE PHYSICIAN GROUP LLC
Other - Org Name:CARDIOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:410-363-3000
Mailing Address - Street 1:2000 WEST BALTIMORE STREET
Mailing Address - Street 2:PHYS SVCS
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223
Mailing Address - Country:US
Mailing Address - Phone:410-362-3603
Mailing Address - Fax:
Practice Address - Street 1:2000 WEST BALTIMORE STREET
Practice Address - Street 2:PHYS SVCS
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223
Practice Address - Country:US
Practice Address - Phone:410-362-3603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BON SECOURS HOSPITAL BALTIMORE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty