=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336404110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF MARYLAND MEDICAL REGIONAL SUPPLIER SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2012
-----------------------------------------------------
Last Update Date | 02/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 N HAMMONDS FERRY RD STE C
-----------------------------------------------------
City | LINTHICUM HEIGHTS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21090-1355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-462-3508
-----------------------------------------------------
Fax | 410-296-3207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 N HAMMONDS FERRY RD STE C
-----------------------------------------------------
City | LINTHICUM HEIGHTS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21090-1355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-462-3508
-----------------------------------------------------
Fax | 410-296-3207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | JON BURNS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-462-3508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | C15150
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | C15150
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------