Basic Information
| Provider Information | |||||||||
| NPI: | 1679217244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYS CENTER FOR MATERNAL AND CHILD CARE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200092627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
| FaxNumber: | 2024830302 | ||||||||
| Practice Location | |||||||||
| Address1: | 8908 RIGGS RD | ||||||||
| Address2: | |||||||||
| City: | ADELPHI | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207831632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8447962797 | ||||||||
| FaxNumber: | 3014225935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2022 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | ELLIOTT | ||||||||
| AuthorizedOfficialFirstName: | TOLLIE | ||||||||
| AuthorizedOfficialMiddleName: | BURKE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2027453119 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.