Healthcare Provider Details

I. General information

NPI: 1679512909
Provider Name (Legal Business Name): SHOCK TRAUMA ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S PACA ST SUITE 500
BALTIMORE MD
21201-1791
US

IV. Provider business mailing address

PO BOX 64793
BALTIMORE MD
21264-4793
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6704
  • Fax: 410-328-4124
Mailing address:
  • Phone: 410-328-6704
  • Fax: 410-328-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY COLLIC
Title or Position: DIRECTOR OF PROFESSIONAL FEES
Credential:
Phone: 667-214-1334