Provider Demographics
NPI:1316962244
Name:BALTIMORE SPINE CENTER, LLC
Entity type:Organization
Organization Name:BALTIMORE SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-828-4789
Mailing Address - Street 1:1300 BELLONA AVE
Mailing Address - Street 2:BUILDING D
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5465
Mailing Address - Country:US
Mailing Address - Phone:410-828-4789
Mailing Address - Fax:410-337-6999
Practice Address - Street 1:1300 BELLONA AVE
Practice Address - Street 2:BUILDING D
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5465
Practice Address - Country:US
Practice Address - Phone:410-828-4789
Practice Address - Fax:410-337-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1413261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD180ZMedicare ID - Type Unspecified