Healthcare Provider Details

I. General information

NPI: 1649090275
Provider Name (Legal Business Name): ST. AGNES HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 WILKENS AVE STE 305
BALTIMORE MD
21229-5218
US

IV. Provider business mailing address

3449 WILKENS AVE STE 305
BALTIMORE MD
21229-5218
US

V. Phone/Fax

Practice location:
  • Phone: 410-368-9992
  • Fax:
Mailing address:
  • Phone: 410-368-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM B HIGGINBOTHAM
Title or Position: PRESIDENT/CEO
Credential:
Phone: 667-234-3162