Basic Information
| Provider Information | |||||||||
| NPI: | 1285765636 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POTOMAC RIDGE- EASTERN SHORE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 FIELDCREST RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216139423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102210288 | ||||||||
| FaxNumber: | 4102219588 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 FIELDCREST RD | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216139423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102210288 | ||||||||
| FaxNumber: | 4102219588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4102210288 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MA, ATR | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 5337 | MD | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 410520600 | 05 | MD | MEDICAID | 410978300 | 05 | MD | MEDICAID |