Healthcare Provider Details

I. General information

NPI: 1275361297
Provider Name (Legal Business Name): BACKPACK MEDICAL GROUP OF KS ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 SANTA BARBARA RD UNIT 8574
ELKRIDGE MD
21075-7523
US

IV. Provider business mailing address

6655 SANTA BARBARA RD UNIT 8574
ELKRIDGE MD
21075-7523
US

V. Phone/Fax

Practice location:
  • Phone: 630-306-4394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LOSHAWN KING
Title or Position: INSURANCE SPECIALIST
Credential:
Phone: 407-779-5617