=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821079997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERIATRIC MEDICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2434 W BELVEDERE AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-601-2246
-----------------------------------------------------
Fax | 410-601-2924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2434 W BELVEDERE AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-601-2246
-----------------------------------------------------
Fax | 410-601-2924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRNP
-----------------------------------------------------
Name | MRS. LISA LARAY STANTON
-----------------------------------------------------
Credential | MSN
-----------------------------------------------------
Telephone | 410-601-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | R111052
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------