=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427739085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAILWINDS MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 GOODWILL AVE
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21613-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-972-4204
-----------------------------------------------------
Fax | 833-471-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 GOODWILL AVE
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21613-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-972-4204
-----------------------------------------------------
Fax | 833-471-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRANDON ROBERT MCMULLEN
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 443-972-4204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------