Basic Information
| Provider Information | |||||||||
| NPI: | 1639398159 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGITRACE CARE SERVICES INC | ||||||||
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| OtherOrganizationName: | SLEEPMED INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2303 BEL AIR RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | FALLSTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210472737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108773950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE & ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 292359 | 01 | MD | MAMSI | OTHER | 071500008 | 05 | MD | MEDICAID | 292359 | 01 | MD | ONENET PPO | OTHER | 85970002 | 01 | VA | CARE FIRST | OTHER | 292359 | 01 | MD | MDIPA | OTHER | 419630 | 01 | MD | CARE FIRST | OTHER | 520537 | 01 | MD | CARE FIRST | OTHER | 85TZDI | 01 | MD | CARE FIRST | OTHER | 85970001 | 01 | VA | CARE FIRST | OTHER | 292359 | 01 | MD | OPTIMUM CHOICE | OTHER |