Basic Information
Provider Information | |||||||||
NPI: | 1043714306 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATLANTIC GENERAL HOSPITAL CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10026 OLD OCEAN CITY BLVD | ||||||||
Address2: | BUILDING #1 | ||||||||
City: | BERLIN | ||||||||
State: | MD | ||||||||
PostalCode: | 218111288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106419450 | ||||||||
FaxNumber: | 4106419515 | ||||||||
Practice Location | |||||||||
Address1: | 9714 HEALTHWAY DR | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | MD | ||||||||
PostalCode: | 218111154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106413340 | ||||||||
FaxNumber: | 4106413341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2018 | ||||||||
LastUpdateDate: | 11/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOTTINGHAM | ||||||||
AuthorizedOfficialFirstName: | CHERYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
AuthorizedOfficialTelephone: | 4106419602 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ATLANTIC GENERAL HOSPITAL CORP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 208D00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 261QD1600X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.