Healthcare Provider Details

I. General information

NPI: 1013615681
Provider Name (Legal Business Name): GWYNNFALLS MD OPCO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 09/10/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

IV. Provider business mailing address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

V. Phone/Fax

Practice location:
  • Phone: 410-525-1544
  • Fax:
Mailing address:
  • Phone: 410-655-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JACK PANETH
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 410-525-1544