Basic Information
| Provider Information | |||||||||
| NPI: | 1619411121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREDERICK PSYCHIATRIC MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 PEBBLE BEACH TER | ||||||||
| Address2: | |||||||||
| City: | IJAMSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217549147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016067785 | ||||||||
| FaxNumber: | 2403101927 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 PEBBLE BEACH TER | ||||||||
| Address2: | |||||||||
| City: | IJAMSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217549147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016067785 | ||||||||
| FaxNumber: | 2403101927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2016 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | CORVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3016067785 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | DOO44857 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 60054 | 01 | MD | AETNA | OTHER | MDMCD | 05 | MD | MEDICAID | 00823 | 01 | VALUE OPTIONS | OTHER | SKMDO | 05 | MD | MEDICAID | SB580 | 01 | MD | BLUE CROSS/BLUE SHIELD | OTHER | D0044857 | 01 | MD | MEDICAL LICENSE | OTHER | SX173 | 01 | MD | BEACON HEALTH | OTHER |