Provider Demographics
NPI:1720227176
Name:ST. AGNES HEALTHCARE, INC.
Entity Type:Organization
Organization Name:ST. AGNES HEALTHCARE, INC.
Other - Org Name:GEORGE THOMAS GRACE M.D. SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDER KOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:667-234-2101
Mailing Address - Street 1:3585 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1676
Mailing Address - Country:US
Mailing Address - Phone:667-234-2149
Mailing Address - Fax:667-234-8644
Practice Address - Street 1:300 FREDERICK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4665
Practice Address - Country:US
Practice Address - Phone:410-744-0900
Practice Address - Fax:410-744-3160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. AGNES HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-09
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1300261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical