Healthcare Provider Details

I. General information

NPI: 1497274013
Provider Name (Legal Business Name): PREMISE HEALTH OF MARYLAND MEDICAL P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CHESAPEAKE PARK PLZ
MIDDLE RIVER MD
21220-4201
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 410-682-1609
  • Fax: 410-682-1458
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES M THIEL
Title or Position: PRESIDENT
Credential: MD
Phone: 844-407-7557