Basic Information
| Provider Information | |||||||||
| NPI: | 1649419235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUILLIN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11544 QUILLIN WAY | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218112567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106291126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11827 OCEAN GATEWAY | ||||||||
| Address2: | WORCESTER COUNTY HEALTH DEPARTMENT - WACS CENTER | ||||||||
| City: | OCEAN CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102130202 | ||||||||
| FaxNumber: | 4102131408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2009 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | AC0740 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 705371101 | 05 | MD | MEDICAID |