Healthcare Provider Details

I. General information

NPI: 1902763162
Provider Name (Legal Business Name): CKNMG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

IV. Provider business mailing address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

V. Phone/Fax

Practice location:
  • Phone: 866-233-6925
  • Fax:
Mailing address:
  • Phone: 866-233-6925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY JANE FAVAZZA
Title or Position: CEO
Credential:
Phone: 410-528-7109