MEDICARE: STATE OF MARLYAND

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1083837	OTHER	MD	AETNA HMO PROVIDER
2	7719711	OTHER	MD	AETNA INDEMNITY PROVIDER
3	54256405	OTHER	MD	BCBS RENDERING PROVIDER
4	9571898	OTHER	MD	CIGNA PROVIDER NUMBER

General Provider Information

NPI Number	:	1538286174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MARLYAND

Provider Business Mailing Address
First Line	:	1000 HILLTOP CIR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21250-0001
Country	:	US
Telephone Number	:	410-455-2543
Fax Number	:	410-455-1125

Provider Business Practice Location Address
First Line	:	1000 HILLTOP CIR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21250-0001
Country	:	US
Telephone Number	:	410-455-2543
Fax Number	:	410-455-1125

Authorized Official
Title or Position	:	HEALTH CENTER DIRECTOR
Name	:	MRS. JENNIFER LEPUS
Credential	:	M.A.
Telephone Number	:	410-455-3751

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	08/22/2020

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Directions to “STATE OF MARLYAND ” Practice Location

Language	Start Address	Practice Location

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