Basic Information
| Provider Information | |||||||||
| NPI: | 1497013585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUALITY CARE INTERNET, LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | QCI BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2525 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206042525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016433975 | ||||||||
| FaxNumber: | 3018120207 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N BURHANS BLVD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217404677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016433975 | ||||||||
| FaxNumber: | 3018120207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | RICHMOND | ||||||||
| AuthorizedOfficialFirstName: | MILLIE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3016433975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 782540401 | 05 | MD | MEDICAID |