| Autumn Lake At Ruxton Psy | |
|
821 N Charles St Baltimore MD 21201-5307 | |
| (410) 838-7810 | |
| Not Available |
| Full Name | Autumn Lake At Ruxton Psy |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 821 N Charles St, Baltimore, Maryland |
| Authorized Official Name and Position | Krystle Brown (BILLING MANAGER) |
| Authorized Official Contact | 4108709380 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Autumn Lake At Ruxton Psy 821 N Charles St Baltimore MD 21201-5307 Ph: () - | Autumn Lake At Ruxton Psy 821 N Charles St Baltimore MD 21201-5307 Ph: (410) 838-7810 |
| NPI Number | 1932968856 |
|---|---|
| Provider Enumeration Date | 03/14/2024 |
| Last Update Date | 07/24/2024 |
| Certification Date | 07/24/2024 |
| Medicare PECOS PAC ID | 3678911625 |
|---|---|
| Medicare Enrollment ID | O20240503003481 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1932968856 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Secondary |
| 363LP0808X | Nurse Practitioner - Psychiatric/mental Health | (* (Not Available)) | Primary |
| Provider Name | Beserat Legesse Kibret |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578139689 PECOS PAC ID: 9234526120 Enrollment ID: I20220422002197 |
| Provider Name | Kehinde Laniyi |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1720553662 PECOS PAC ID: 0648505313 Enrollment ID: I20220517000088 |
| Provider Name | Moses Njoki |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578047973 PECOS PAC ID: 9931445848 Enrollment ID: I20230608001001 |
| Provider Name | Walter Lewis Toller |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760060636 PECOS PAC ID: 9537572839 Enrollment ID: I20231030003361 |
| Provider Name | Kamal Salah H Sewaralthahab |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1689939035 PECOS PAC ID: 2365757291 Enrollment ID: I20231107001185 |
| Provider Name | Fobella Anyiji Nzobella |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750164521 PECOS PAC ID: 1951741180 Enrollment ID: I20240513002538 |
| Provider Name | Dympna Ndelle |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1386414480 PECOS PAC ID: 8628511979 Enrollment ID: I20240614003565 |
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