=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275355240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER BALTIMORE MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10803 FALLS RD PAVILION III STE 3100
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-4582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-616-7650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6701 N. CHARLES STREET S. CHAPMAN BUILDING, SUITE 102
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP & CFO
-----------------------------------------------------
Name | LAURIE R BEYER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-849-2519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------