Basic Information
| Provider Information | |||||||||
| NPI: | 1396400248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUH KIDS MOBILE MEDICAL CLINIC PROGRAM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 RESERVOIR RD NW | ||||||||
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| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200072113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035581217 | ||||||||
| FaxNumber: | 7035581445 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 WISCONSIN AVE NW STE 400 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200162100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024448888 | ||||||||
| FaxNumber: | 2024444315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2021 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | SCHNEIDER | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7025581403 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.