Healthcare Provider Details

I. General information

NPI: 1689857096
Provider Name (Legal Business Name): BALTIMORE CENTER FOR FACIAL PLASTIC SURGERY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 N CHARLES ST PHYSICIANS PAVILION NORTH
BALTIMORE MD
21204-5826
US

IV. Provider business mailing address

6535 N CHARLES ST PHYSICIANS PAVILION NORTH
BALTIMORE MD
21204-5826
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-4123
  • Fax: 410-848-4124
Mailing address:
  • Phone: 410-848-4123
  • Fax: 410-848-4124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberD0060483
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD0060483
License Number StateMD

VIII. Authorized Official

Name: DR. RANDOLPH BAKER CAPONE
Title or Position: OWNER
Credential: M.D.
Phone: 410-848-4123