Basic Information
Provider Information | |||||||||
NPI: | 1639293228 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACHD-DENTAL PROGRAM | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1745 | ||||||||
Address2: |   | ||||||||
City: | CUMBERLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215011745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017595000 | ||||||||
FaxNumber: | 3017775674 | ||||||||
Practice Location | |||||||||
Address1: | 12503 WILLOWBROOK RD | ||||||||
Address2: |   | ||||||||
City: | CUMBERLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215022554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017595030 | ||||||||
FaxNumber: | 3017224304 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2007 | ||||||||
LastUpdateDate: | 08/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAVER | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3017595001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD, MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
ID | Type | State | Issuer | Description | 722001500 | 05 | MD |   | MEDICAID | 720001300 | 05 | MD |   | MEDICAID |