Healthcare Provider Details

I. General information

NPI: 1497102867
Provider Name (Legal Business Name): PIKESVILLE HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 GREENWOOD RD
BALTIMORE MD
21208
US

IV. Provider business mailing address

2833 SMITHE AVE SUITE # 148
BALTIMORE MD
21209
US

V. Phone/Fax

Practice location:
  • Phone: 410-415-6384
  • Fax:
Mailing address:
  • Phone: 410-415-6384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number906136
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number906136
License Number StateMD

VIII. Authorized Official

Name: AMIEL CHICHEPORTICHE
Title or Position: PROGRAM SPONSOR
Credential: BS
Phone: 410-415-6384