Healthcare Provider Details

I. General information

NPI: 1245274901
Provider Name (Legal Business Name): ST. AGNES HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CATON AVE
BALTIMORE MD
21229-5201
US

IV. Provider business mailing address

3585 WASHINGTON BLVD
HALETHORPE MD
21227-1676
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-2126
  • Fax: 667-238-2947
Mailing address:
  • Phone: 667-234-2126
  • Fax: 667-234-2947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number282N00000X
License Number StateMD

VIII. Authorized Official

Name: MR. KEITH VANDER KOLK
Title or Position: PRESIDENT/CEO
Credential:
Phone: 667-234-2101