Healthcare Provider Details

I. General information

NPI: 1699774018
Provider Name (Legal Business Name): LIFESTAR RESPONSE OF MARYLAND, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10840 GUILFORD RD STE 404
ANNAPOLIS JUNCTION MD
20701-1110
US

IV. Provider business mailing address

PO BOX 827284
PHILADELPHIA PA
19182-7284
US

V. Phone/Fax

Practice location:
  • Phone: 410-247-1178
  • Fax: 410-536-5476
Mailing address:
  • Phone: 410-247-1178
  • Fax: 410-536-5476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number74
License Number StateMD

VIII. Authorized Official

Name: ADAM KOONTZ
Title or Position: REGIONAL CEO
Credential:
Phone: 929-464-4888