NPIMap

Organization Active NPI

Baltimore Medical System Inc

  • Federally Qualified Health Center (FQHC)
  • Baltimore, MD
National Provider Identifier
1902802705
Registry record updated Jun 15, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BALTIMORE MEDICAL SYSTEM INC
Practice address
3120 Erdman Ave
Baltimore, MD 21213-1720
Phone
(410) 558-4800
Fax
(410) 675-8947
NPI assigned
Jun 27, 2005
Reactivated
Jun 1, 2023
Last updated
Jun 15, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 15, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shirley Sutton
Title
President and Ceo
Phone
(410) 558-4891

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

3120 Erdman Ave
Baltimore, MD 21213-1720

Mailing address

5525 Eastern Ave Ste 301
Baltimore, MD 21224-2796
Phone (410) 732-8800

Other identifiers 2

IdentifierTypeStateIssuer
376751500MedicaidMD
376751502MedicaidMD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040122000785 MD Part A Provider - Federally Qualified Health Center (FQHC) 5395653455 Practice locations: Baltimore, MD

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902802705. Details of each certification follow.

Federally qualified health center certification: CCN 211816

Legal name
BALTIMORE MEDICAL SYSTEM, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 25, 1995
Last certification
Apr 25, 1995
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1985 in MD
Enrollment address
3120 Erdman Ave
Baltimore, MD 21213-1720
Related CCNs
211810

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Baltimore Medical System Inc24 organizations share this tax ID, including this one

Other organizations with this tax ID 22

Organizations that report the same tax identification number in the National Provider Directory.

View all 22

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Octavius Mewborn Individual Corporate OfficerBoard Member Nov 1, 2014
Shirley Sutton Individual Corporate OfficerCeo Mar 1, 2015
Allison Mackenzie Individual Corporate OfficerBoard Member Chair Jul 27, 2015
Lisa L Holly Individual W-2 Managing EmployeePrivileging/Credentialing Team Lead Jun 29, 2015
Sarah Norman Individual Corporate OfficerBoard Member Feb 25, 2013
Yolanda Copeland Individual Corporate OfficerBoard Member Dec 19, 2016
Christopher Demarco Individual Corporate OfficerBoard Member Jan 1, 2018
Cheryl Bryant Individual Corporate OfficerBoard Member Aug 24, 2015
Eric Thompson Individual Corporate OfficerBoard Member Dec 21, 2015
Rebecca Dawson Individual W-2 Managing EmployeeAr Supervisor Jan 1, 2021
Margaret Boemmel Individual Corporate OfficerChief Financial Officer Dec 16, 2019
Scarlett Watson Individual Corporate OfficerBoard Member May 1, 2015
Michael Banfield Individual Corporate OfficerBoard Member Jan 23, 2017
Arif Khan Individual Corporate OfficerBoard Member Dec 19, 2016
Christina McWilliams Individual Corporate OfficerBoard Member Aug 24, 2015

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119830400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1686787200000",
    "number": "1902802705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5525 EASTERN AVE STE 301",
            "city": "BALTIMORE",
            "state": "MD",
            "postal_code": "212242796",
            "telephone_number": "410-732-8800",
            "fax_number": "410-327-1693"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3120 ERDMAN AVE",
            "city": "BALTIMORE",
            "state": "MD",
            "postal_code": "212131720",
            "telephone_number": "410-558-4800",
            "fax_number": "410-675-8947"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BALTIMORE MEDICAL SYSTEM INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-27",
        "last_updated": "2023-06-15",
        "certification_date": "2023-06-15",
        "deactivation_date": "2023-05-13",
        "reactivation_date": "2023-06-01",
        "status": "A",
        "authorized_official_last_name": "SUTTON",
        "authorized_official_first_name": "SHIRLEY",
        "authorized_official_title_or_position": "PRESIDENT AND CEO",
        "authorized_official_telephone_number": "410-558-4891"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "376751500",
            "state": "MD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "376751502",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Baltimore, MD

Sources for this page

Verify at the official NPI Registry.