Healthcare Provider Details

I. General information

NPI: 1043143498
Provider Name (Legal Business Name): MARVIN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E 22ND ST
BALTIMORE MD
21218-5407
US

IV. Provider business mailing address

13719 JARRETTSVILLE PIKE
PHOENIX MD
21131-2021
US

V. Phone/Fax

Practice location:
  • Phone: 443-769-2377
  • Fax:
Mailing address:
  • Phone: 443-769-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: