Provider Demographics
NPI:1104253160
Name:TOTAL IMAGE CARE, INC.
Entity type:Organization
Organization Name:TOTAL IMAGE CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:410-560-0614
Mailing Address - Street 1:1850 YORK RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5122
Mailing Address - Country:US
Mailing Address - Phone:410-560-0614
Mailing Address - Fax:410-560-0613
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:SUITE 11
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-3224
Practice Address - Fax:443-643-3227
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOTAL IMAGE CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF807OtherCAREFIRST BLUE CROSS BLUE SHIELD
MD6010000800Medicaid
MDMH24OtherCAREFIRST BLUE CROSS BLUE SHIELD