Provider Demographics
NPI:1841344470
Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Entity type:Organization
Organization Name:SHEPPARD PRATT HEALTH SYSTEM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE BUSINESS DEVELOPMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-938-3150
Mailing Address - Street 1:6501 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6819
Mailing Address - Country:US
Mailing Address - Phone:410-938-3150
Mailing Address - Fax:410-938-3159
Practice Address - Street 1:10100 COUNTRY CLUB RD SE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-8339
Practice Address - Country:US
Practice Address - Phone:410-777-2258
Practice Address - Fax:301-777-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3794261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD201901902Medicaid
MD214000Medicare PIN