=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184817702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSPRING CARDIAC CARE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 10/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 WEST RD BUILDING A, SUITE 201
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-307-1090
-----------------------------------------------------
Fax | 410-307-1095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10845 PHILADELPHIA RD
-----------------------------------------------------
City | WHITE MARSH
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21162-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-335-0008
-----------------------------------------------------
Fax | 410-335-1133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JORGE C. SECADA-LOVIO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 410-307-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | D0022633
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------