MEDICARE: BALTIMORE COMMUNITY RESOURCE CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	9789	MD

General Provider Information

NPI Number	:	1134100647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALTIMORE COMMUNITY RESOURCE CENTER, INC.

Provider Business Mailing Address
First Line	:	21 W 25TH ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-5003
Country	:	US
Telephone Number	:	410-366-1717
Fax Number	:	410-889-4167

Provider Business Practice Location Address
First Line	:	1049 ROLAND HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21211-1239
Country	:	US
Telephone Number	:	410-243-3039
Fax Number	:	410-889-4167

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. ROBIN WOODELL
Credential	:
Telephone Number	:	410-366-1717

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/24/2009

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