Basic Information
| Provider Information | |||||||||
| NPI: | 1003968991 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACHD-OUTPATIENT ADDICTIONS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1745 | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215011745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595000 | ||||||||
| FaxNumber: | 3017775674 | ||||||||
| Practice Location | |||||||||
| Address1: | 12501-12503 WILLOWBROOK RD | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595050 | ||||||||
| FaxNumber: | 3017772098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAVER | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3017595001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 903070 | MD | N | Agencies | Community/Behavioral Health | 261QM2800X | 903068 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 251S00000X | 903069 | MD | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 351541 | 01 | MAMSI | OTHER | KO | 01 | MAGELLAN | OTHER | 323817 | 01 | VALUE OPTIONS | OTHER | 702001500 | 05 | MD | MEDICAID | O2KO | 01 | MAGELLAN | OTHER | 8480502 | 01 | UBH (MCO) | OTHER | 55752NO | 01 | PRIORITY PARTNERS (MCO) | OTHER | 604116-04 | 01 | CAREFIRST BCBS | OTHER | NU1 | 01 | GHMSI | OTHER | 1059446 | 01 | CIGNA | OTHER |