Basic Information
| Provider Information | |||||||||
| NPI: | 1467495523 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES COUNTY COUNTY COMMISSIONERS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 630354 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212630354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432742900 | ||||||||
| FaxNumber: | 4432742589 | ||||||||
| Practice Location | |||||||||
| Address1: | 10425 AUDLE LANE | ||||||||
| Address2: | |||||||||
| City: | LAPLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016093400 | ||||||||
| FaxNumber: | 3016093410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3016093402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 406085700 | 05 | MD | MEDICAID | 386BCH | 01 | MD | BCBS GROUP PROVIDER # | OTHER | K086 | 01 | DC | BCBS GROUP PROVIDER # | OTHER |