Healthcare Provider Details

I. General information

NPI: 1205197183
Provider Name (Legal Business Name): VILLAGE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E UNIVERSITY PKWY SUITE109
BALTIMORE MD
21218-2451
US

IV. Provider business mailing address

1 E UNIVERSITY PKWY SUITE109
BALTIMORE MD
21218-2451
US

V. Phone/Fax

Practice location:
  • Phone: 410-235-1601
  • Fax:
Mailing address:
  • Phone: 410-235-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0055808
License Number StateMD

VIII. Authorized Official

Name: DR. ALICIA MORGAN COOPER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-235-1601