Basic Information
| Provider Information | |||||||||
| NPI: | 1306408612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC GENERAL HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | AGHS BEHAVORIAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10026 OLD OCEAN CITY BLVD, BLDG 1 | ||||||||
| Address2: | AGHS PHYSICIAN BILLING OFFICE | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106296007 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9714 HEALTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106413340 | ||||||||
| FaxNumber: | 4106413341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2019 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | NOTTINGHAM | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | LEWIS | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4106419602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2084P0804X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 2080P0008X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2084P0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 514300400 | 05 | MD | MEDICAID |