=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679512909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHOCK TRAUMA ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2006
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 S PACA ST SUITE 500
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-328-6704
-----------------------------------------------------
Fax | 410-328-4124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 64793
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21264-4793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-328-6704
-----------------------------------------------------
Fax | 410-328-4214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PROFESSIONAL FEES
-----------------------------------------------------
Name | MS. KIMBERLY COLLIC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 667-214-1334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------