Basic Information
| Provider Information | |||||||||
| NPI: | 1003035510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGITRACE CARE SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SLEEPMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6931 ARLINGTON RD | ||||||||
| Address2: | T300-A | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208145231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012515905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE & ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 071500005 | 05 | MD | MEDICAID | 292359 | 01 | MD | MDIPA | OTHER | 292359 | 01 | MD | OPTIMUM CHOICE | OTHER | 292359 | 01 | MD | MAMSI | OTHER | 659561 | 01 | MD | SOUTHERN HEALTH | OTHER | 292359 | 01 | MD | ONENET PPO | OTHER | 419630 | 01 | MD | CARE FIRST | OTHER | 85970002 | 01 | VA | CARE FIRST | OTHER | 85970001 | 01 | VA | CARE FIRST | OTHER | 8597001 | 01 | VA | CARE FIRST | OTHER | 520537 | 01 | MD | CARE FIRST | OTHER | 85TZDI | 01 | MD | CARE FIRST | OTHER |