Basic Information
| Provider Information | |||||||||
| NPI: | 1568468221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVENTIST HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTIST HEALTHCARE SHADY GROVE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 W DIAMOND AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208781419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013153030 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9901 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208503357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2408266000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER AND SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 3013153030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 15315 | MD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 402824400 | 05 | MD | MEDICAID |