Basic Information
| Provider Information | |||||||||
| NPI: | 1336647577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JASON A TATE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 973 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211580973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108485785 | ||||||||
| FaxNumber: | 4108485629 | ||||||||
| Practice Location | |||||||||
| Address1: | 76 FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | TANEYTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217872135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107569110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | TATE | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4107569110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1906011 | 05 | MD | MEDICAID |