Basic Information
| Provider Information | |||||||||
| NPI: | 1104914464 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAY STATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHERPPARD PRATT AT HOWARD COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 230 W PATRICK ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217016945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016620099 | ||||||||
| FaxNumber: | 3016949932 | ||||||||
| Practice Location | |||||||||
| Address1: | 9030 STATE ROUTE 108 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210451951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107401901 | ||||||||
| FaxNumber: | 4107408932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C E O | ||||||||
| AuthorizedOfficialTelephone: | 3016620099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | T806 | 01 | MD | BLUE CHOICE GROUP NUMBER | OTHER | K011WA | 01 | MD | MDBCBS GROUP NUMBER | OTHER |