=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184884603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF MARYLAND FAMILY MEDICINE ASSOCIATES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 10/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 S PACA ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-328-2832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 64380
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21264-4380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-328-2832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR ADMINISTRATOR
-----------------------------------------------------
Name | MS. KATHY A. MADDOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-328-2832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------