Basic Information
Provider Information | |||||||||
NPI: | 1023757713 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARYLAND FAMILY CARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 824173 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191824173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106592963 | ||||||||
FaxNumber: | 4103329789 | ||||||||
Practice Location | |||||||||
Address1: | 301 ST PAUL PLACE | ||||||||
Address2: | MEDICAL STAFF OFFICE | ||||||||
City: | BALTIMORE, MD 21202 | ||||||||
State: | MD | ||||||||
PostalCode: | 21202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106592963 | ||||||||
FaxNumber: | 4103329789 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2022 | ||||||||
LastUpdateDate: | 06/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUNCAN | ||||||||
AuthorizedOfficialFirstName: | JANELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 4106592963 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.