Healthcare Provider Details

I. General information

NPI: 1447585120
Provider Name (Legal Business Name): CAG GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PARK AVE
BALTIMORE MD
21217-4104
US

IV. Provider business mailing address

7095 HOLLYWOOD BLVD SUITE 338
HOLLYWOOD CA
90028-8903
US

V. Phone/Fax

Practice location:
  • Phone: 443-927-7364
  • Fax: 800-419-7485
Mailing address:
  • Phone: 443-927-7364
  • Fax: 800-419-7485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21D0649684
License Number StateMD

VIII. Authorized Official

Name: MAURICE M VINCENT
Title or Position: PRESIDENT
Credential: MD
Phone: 443-927-7364