=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568508927
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN GROUP WPCC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 W FAYETTE ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-209-6201
-----------------------------------------------------
Fax | 410-209-6209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 630 W FAYETTE ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-209-6201
-----------------------------------------------------
Fax | 410-209-6209
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ARCHIE T. WALLACE
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 410-209-6201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------