=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528096377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER BALTIMORE MEDICAL CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 03/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6569 N CHARLES ST STE 701
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21204-6831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-849-3431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 631568
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21263-1568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRES & CFO
-----------------------------------------------------
Name | MR. ERIC MELCHIOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-849-2519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------