Basic Information
| Provider Information | |||||||||
| NPI: | 1134512403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BEHAVIORAL HEALTH JACKSON UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1745 | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215011745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017595000 | ||||||||
| FaxNumber: | 3017775674 | ||||||||
| Practice Location | |||||||||
| Address1: | 10102 COUNTRY CLUB RD SE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215028339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017772290 | ||||||||
| FaxNumber: | 3017772141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAVER | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | ALLEGANY COUNTY HEALTH OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3017595000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D., M.P.H. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 904691 | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
| ID | Type | State | Issuer | Description | 277593 | 01 | MAMSI | OTHER | 323817 | 01 | VALUE OPTIONS | OTHER | 603304100 | 05 | MD | MEDICAID |