Healthcare Provider Details

I. General information

NPI: 1124845391
Provider Name (Legal Business Name): BALTIMORE CHILDREN'S GAD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 BENSON AVE STE G100
BALTIMORE MD
21227-1134
US

IV. Provider business mailing address

3421 BENSON AVE STE G100
BALTIMORE MD
21227-1134
US

V. Phone/Fax

Practice location:
  • Phone: 410-417-7777
  • Fax:
Mailing address:
  • Phone: 410-417-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY WHEELER
Title or Position: CEO
Credential:
Phone: 301-494-3000