Healthcare Provider Details

I. General information

NPI: 1801474432
Provider Name (Legal Business Name): SHANNON MARIE BOLTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST # N5W70
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

22 S GREENE ST # N5W70
BALTIMORE MD
21201-1544
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6960
  • Fax: 410-328-0646
Mailing address:
  • Phone: 410-328-6960
  • Fax: 410-328-0646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0099725
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: