Healthcare Provider Details

I. General information

NPI: 1598778623
Provider Name (Legal Business Name): USCG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 HAWKINS POINT RD
BALTIMORE MD
21226-1797
US

IV. Provider business mailing address

2401 HAWKINS POINT RD
BALTIMORE MD
21226-1797
US

V. Phone/Fax

Practice location:
  • Phone: 410-636-7506
  • Fax:
Mailing address:
  • Phone: 410-636-7506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1101X
TaxonomyMilitary and U.S. Coast Guard Ambulatory Procedure Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AARON E. FULTCHER
Title or Position: CLINIC ADMINISTRATOR
Credential: CWO
Phone: 410-636-7506