Healthcare Provider Details

I. General information

NPI: 1629943972
Provider Name (Legal Business Name): ST PAUL PLACE SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11121 YORK RD
HUNT VALLEY MD
21030-2006
US

IV. Provider business mailing address

301 ST PAUL PLACE MEDICAL STAFF OFFICE
BALTIMORE MD
21202-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9000
  • Fax:
Mailing address:
  • Phone: 410-659-2963
  • Fax: 410-332-9789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JUSTIN DEIBEL
Title or Position: EXECUTIVE VICE PRESIDENT/CFO
Credential:
Phone: 410-659-2905