=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700539269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIKESVILLE HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2022
-----------------------------------------------------
Last Update Date | 02/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 GREENWOOD RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-258-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2833 SMITH AVE STE 148
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-258-8939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM SPONSOR
-----------------------------------------------------
Name | AMIEL CHICHEPORTICHE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-484-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------