Basic Information
| Provider Information | |||||||||
| NPI: | 1558718668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALVERTHEALTH MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | CALVERTHEALTH OUTPATIENT REHABILITATION PRINCE FREDERICK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | ATT: CONTRACT & CREDENTIALING | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144558 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358180 | ||||||||
| FaxNumber: | 4105358325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2016 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| 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 | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225200000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 728804202 | 05 | MD | MEDICAID |