Provider Demographics
NPI:1063722171
Name:BLACKWATER MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:BLACKWATER MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MALKUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-228-1068
Mailing Address - Street 1:408 BYRN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1910
Mailing Address - Country:US
Mailing Address - Phone:410-228-1068
Mailing Address - Fax:410-228-6338
Practice Address - Street 1:408 BYRN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1910
Practice Address - Country:US
Practice Address - Phone:410-228-1068
Practice Address - Fax:410-228-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0080504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD781000800Medicaid
MD781000800Medicaid