Basic Information
Provider Information | |||||||||
NPI: | 1679842462 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GARRETT COUNTY PERSONAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1025 MEMORIAL DR | ||||||||
Address2: | 1025 MEMORIAL DRIVE | ||||||||
City: | OAKLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215504343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013347700 | ||||||||
FaxNumber: | 3013347717 | ||||||||
Practice Location | |||||||||
Address1: | 1025 MEMORIAL DR | ||||||||
Address2: | 1025 MEMORIAL DRIVE | ||||||||
City: | OAKLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215504343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013347700 | ||||||||
FaxNumber: | 3013347717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2011 | ||||||||
LastUpdateDate: | 02/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GLOTFELTY | ||||||||
AuthorizedOfficialFirstName: | RODNEY | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3013347700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GARRETT COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RS, MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | STATE AGENCY | MD | Y |   | Agencies | Public Health or Welfare |   |
ID Information
ID | Type | State | Issuer | Description | 420919200 | 05 | MD |   | MEDICAID |