Healthcare Provider Details

I. General information

NPI: 1477961829
Provider Name (Legal Business Name): BRIGHTSEAT HEALTH BALTIMORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2972 PENWICK LN
DUNKIRK MD
20754-9403
US

IV. Provider business mailing address

4333 OLD BRANCH AVE
TEMPLE HILLS MD
20748-1848
US

V. Phone/Fax

Practice location:
  • Phone: 301-423-4551
  • Fax:
Mailing address:
  • Phone: 301-423-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDRA HALL
Title or Position: ASST ADMIN
Credential:
Phone: 301-423-4551