Healthcare Provider Details

I. General information

NPI: 1275408916
Provider Name (Legal Business Name): QUEEN GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W NORTH AVE
BALTIMORE MD
21216-3633
US

IV. Provider business mailing address

2500 W NORTH AVE
BALTIMORE MD
21216-3633
US

V. Phone/Fax

Practice location:
  • Phone: 240-604-9471
  • Fax:
Mailing address:
  • Phone: 240-604-9471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1015459
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: