MEDICARE: ST PAUL PLACE SPECIALISTS, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1295603454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST PAUL PLACE SPECIALISTS, INC.

Provider Business Mailing Address
First Line	:	301 ST PAUL PLACE
Second Line	:	MEDICAL STAFF OFFICE
City	:	BALTIMORE
State	:	MD
Zip	:	21202-2102
Country	:	US
Telephone Number	:	410-659-2963
Fax Number	:	410-332-9789

Provider Business Practice Location Address
First Line	:	520 UPPER CHESAPEAKE DR STE 210
Second Line	:
City	:	BEL AIR
State	:	MD
Zip	:	21014-4392
Country	:	US
Telephone Number	:	410-332-9000
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT/CFO
Name	:	JUSTIN DEIBEL
Credential	:
Telephone Number	:	410-659-2905

Provider Enumeration Date	:	10/28/2025
Last Update Date	:	10/28/2025

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