Healthcare Provider Details

I. General information

NPI: 1023775830
Provider Name (Legal Business Name): MALAMA MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 YORK RD
BALTIMORE MD
21212-4726
US

IV. Provider business mailing address

4604 YORK RD
BALTIMORE MD
21212-4726
US

V. Phone/Fax

Practice location:
  • Phone: 443-802-5130
  • Fax:
Mailing address:
  • Phone: 443-902-8017
  • Fax: 443-201-7037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMELA J FERGUSON
Title or Position: OWNER/ NURSE PRACTITIONER
Credential: CNP
Phone: 443-802-5130