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3310 Eastern Ave Fl 1 Baltimore MD 21224-4108 | |
| (667) 309-9920 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 3310 Eastern Ave Fl 1, Baltimore, Maryland |
| Authorized Official Name and Position | Vernon Holmes (CEO) |
| Authorized Official Contact | 6673099920 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3310 Eastern Ave Baltimore MD 21224-4108 Ph: (667) 309-9920 | 3310 Eastern Ave Fl 1 Baltimore MD 21224-4108 Ph: (667) 309-9920 |
| NPI Number | 1114348463 |
|---|---|
| Provider Enumeration Date | 01/03/2014 |
| Last Update Date | 12/25/2024 |
| Certification Date | 12/25/2024 |
| Medicare PECOS PAC ID | 6901182963 |
|---|---|
| Medicare Enrollment ID | O20170406001230 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114348463 | NPI | - | NPPES |
| 424340400 | Medicaid | MD | |
| 180702672 | Other | MD | MARYLAND DEPARTMENT OF HEALTH BEHAVIORAL HEALTH ADMINISTRATION |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | George C Carter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639516388 PECOS PAC ID: 0244456804 Enrollment ID: I20140717001511 |
| Provider Name | Carole Tchatchoua |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1447718549 PECOS PAC ID: 2466861356 Enrollment ID: I20210518001665 |
| Provider Name | Patience Chia |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427664200 PECOS PAC ID: 1850785221 Enrollment ID: I20220304001280 |
| Provider Name | Lawrencia Oluchi Ugochukwu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306569637 PECOS PAC ID: 9739547225 Enrollment ID: I20230615000016 |
| Provider Name | Latria Rogers |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1265718506 PECOS PAC ID: 6709223100 Enrollment ID: I20240412003898 |
| Provider Name | Omoseke Olasesan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912338716 PECOS PAC ID: 4082052758 Enrollment ID: I20240515001925 |
| Provider Name | Giesel Nguty Kemani |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639865645 PECOS PAC ID: 5092251462 Enrollment ID: I20240722001651 |
| Provider Name | Julia Enenu Osemi- Akpama |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164241907 PECOS PAC ID: 6103352166 Enrollment ID: I20241213001370 |
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