Healthcare Provider Details

I. General information

NPI: 1427720481
Provider Name (Legal Business Name): SHOCK TRAUMA ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64793
BALTIMORE MD
21264-4795
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6704
  • Fax:
Mailing address:
  • Phone: 410-328-6704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KIMBERLY COLLIC
Title or Position: DIRECTOR OF REIMBURSEMENT OPERATION
Credential:
Phone: 667-214-1334