Healthcare Provider Details

I. General information

NPI: 1265068373
Provider Name (Legal Business Name): BODYWORKS MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. AGNES MEDICAL CENTER 3455 WILKENS AVE SUITE 100
BALTIMORE MD
21229
US

IV. Provider business mailing address

13013 DAVENPORT DR
BRANDYWINE MD
20613-5683
US

V. Phone/Fax

Practice location:
  • Phone: 240-447-8036
  • Fax:
Mailing address:
  • Phone: 202-270-7542
  • Fax: 240-213-2335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP SHERMAN RAGLAND
Title or Position: PRESIDENT
Credential: MD
Phone: 240-448-3279