Basic Information
| Provider Information | |||||||||
| NPI: | 1265730964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE SHOEMAKER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6655 SYKESVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SYKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217847966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108761989 | ||||||||
| FaxNumber: | 4108761690 | ||||||||
| Practice Location | |||||||||
| Address1: | 6655 SYKESVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SYKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217847966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108761989 | ||||||||
| FaxNumber: | 4108761690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3014472361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 903968 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 416228500 | 05 | MD | MEDICAID |