Provider Demographics
NPI:1558706549
Name:JLJ MEDICAL LLC
Entity type:Organization
Organization Name:JLJ MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:EMANUEL
Authorized Official - Last Name:GRUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-522-0001
Mailing Address - Street 1:217 E CHURCHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:703-522-2727
Mailing Address - Fax:410-552-0017
Practice Address - Street 1:3500 BOSTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5251
Practice Address - Country:US
Practice Address - Phone:410-522-0001
Practice Address - Fax:410-552-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-03
Last Update Date:2024-07-15
Deactivation Date:2024-06-24
Deactivation Code:
Reactivation Date:2024-07-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD422085400Medicaid