=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730053406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND SPINE CENTER CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7602 BELAIR RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21236-4088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-539-3434
-----------------------------------------------------
Fax | 410-539-3550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 ST PAUL PLACE MEDICAL STAFF OFFICE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21202-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-659-2963
-----------------------------------------------------
Fax | 410-332-9789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | CHARLES EDWARDS II
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-539-3434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------