Basic Information
| Provider Information | |||||||||
| NPI: | 1528272192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | PATIENT ACCOUNTS | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437437 | ||||||||
| FaxNumber: | 4105437020 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | PATIENT ACCOUNTS | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437437 | ||||||||
| FaxNumber: | 4105437020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KARNS | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, PATIENT FINANCIAL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 4105437437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPAM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080H0002X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine | 363AS0400X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | K230 PE | 01 | MD | CAREFIRST BCBS OF MD | OTHER |