=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770684805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND GENERAL CLINICAL PRACTICE GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 827 LINDEN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21264-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-462-5093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 64522
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21264-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-462-5093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | GEORGE SPRINKEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-328-1501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------