Basic Information
Provider Information | |||||||||
NPI: | 1396978417 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARFORD COUNTY HEALTH DEPARTMENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HCHD EDGEWOOD ELEMENTARY 1396978417 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 S HAYS ST | ||||||||
Address2: |   | ||||||||
City: | BEL AIR | ||||||||
State: | MD | ||||||||
PostalCode: | 210143615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108771033 | ||||||||
FaxNumber: | 4104203435 | ||||||||
Practice Location | |||||||||
Address1: | 2100 CEDAR DR | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | MD | ||||||||
PostalCode: | 210402502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108771033 | ||||||||
FaxNumber: | 4104203435 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2009 | ||||||||
LastUpdateDate: | 01/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AUSTIN | ||||||||
AuthorizedOfficialFirstName: | MARCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DEPUTY HEALTH OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4108771033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HARFORD COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
ID | Type | State | Issuer | Description | 411302102 | 05 | MD |   | MEDICAID |