Basic Information
| Provider Information | |||||||||
| NPI: | 1407283302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALVERTHEALTH MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CALVERTHEALTH IMAGING SERVICES AT CCNC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144558 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358320 | ||||||||
| FaxNumber: | 4105358109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2013 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4105358239 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALVERT HEALTH SYSTEM, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | 04-001 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
ID Information
| ID | Type | State | Issuer | Description | 422051000 | 05 | MD | MEDICAID |