Healthcare Provider Details

I. General information

NPI: 1053020412
Provider Name (Legal Business Name): NEW ERA WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 OLD FREDERICK RD STE 2
BALTIMORE MD
21229-2126
US

IV. Provider business mailing address

5411 OLD FREDERICK RD STE 2
BALTIMORE MD
21229-2126
US

V. Phone/Fax

Practice location:
  • Phone: 410-775-6394
  • Fax:
Mailing address:
  • Phone: 410-775-6394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRACY RENNA THOMAS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 410-661-9552