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General NPI Number Information
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NPI Number | 1720227176
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Entity Type | Organization
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Legal Business Name | ST. AGNES HEALTHCARE, INC.
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Dates
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Enumeration Date | 02/09/2009
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Last Update Date | 02/25/2016
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Provider Practice Location Address
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Address Line | 300 FREDERICK RD SUITE 200
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City | BALTIMORE
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State | MD
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Zip | 21228-4665
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Country | US
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Telephone | 410-744-0900
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Fax | 410-744-3160
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Provider Business Mailing Address
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Address Line | 3585 WASHINGTON BLVD
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City | HALETHORPE
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State | MD
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Zip | 21227-1676
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Country | US
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Telephone | 667-234-2149
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Fax | 667-234-8644
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MR. KEITH VANDER KOLK
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Credential |
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Telephone | 667-234-2101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | A1300
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License Number State | MD
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