Provider Demographics
NPI:1801283411
Name:ASSOCIATED CATHOLIC CHARITIES
Entity type:Organization
Organization Name:ASSOCIATED CATHOLIC CHARITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CANOSA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-252-4700
Mailing Address - Street 1:1966 GREENSPRING DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4117
Mailing Address - Country:US
Mailing Address - Phone:443-798-3395
Mailing Address - Fax:410-561-7752
Practice Address - Street 1:229 N POTOMAC ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-3812
Practice Address - Country:US
Practice Address - Phone:301-733-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419835208Medicaid