Basic Information
Provider Information | |||||||||
NPI: | 1063677326 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED CATHOLIC CHARITIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLA MARIA OF MOUNTAIN MARYLAND | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 DULANEY VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | TIMONIUM | ||||||||
State: | MD | ||||||||
PostalCode: | 210932739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6676002249 | ||||||||
FaxNumber: | 6676004068 | ||||||||
Practice Location | |||||||||
Address1: | 308 VIRGINIA AVE | ||||||||
Address2: |   | ||||||||
City: | CUMBERLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 21502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6676002110 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2008 | ||||||||
LastUpdateDate: | 01/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REEVES | ||||||||
AuthorizedOfficialFirstName: | GLORIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | A/R AND BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6676002249 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2020 |
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) |
ID Information
ID | Type | State | Issuer | Description | 110171419 | 05 | MD |   | MEDICAID | 110171420 | 05 | MD |   | MEDICAID |