Healthcare Provider Details

I. General information

NPI: 1518787142
Provider Name (Legal Business Name): SETON MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 NORTH RIDGE ROAD SUITE 103
ELLICOTT CITY MD
21043-3396
US

IV. Provider business mailing address

2850 NORTH RIDGE ROAD SUITE 103
ELLICOTT CITY MD
21043-3396
US

V. Phone/Fax

Practice location:
  • Phone: 410-465-8119
  • Fax:
Mailing address:
  • Phone: 410-465-8119
  • 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

VIII. Authorized Official

Name: MR. WILLIAM B HIGGINBOTHAM
Title or Position: PRESIDENT/CEO
Credential:
Phone: 667-234-3162