Basic Information
| Provider Information | |||||||||
| NPI: | 1124397914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GARRETT COUNTY SUBSTANCE ABUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215504343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013347700 | ||||||||
| FaxNumber: | 3013347717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215504343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013347700 | ||||||||
| FaxNumber: | 3013347717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2011 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | GLOTFELTY | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3013347700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GARRETT COUNTY HEALTH DEPARTMENT | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RS, MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | STATE AGENCY | MD | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 420918400 | 05 | MD | MEDICAID |