Basic Information
| Provider Information | |||||||||
| NPI: | 1689985194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOPTANK COMMUNITY HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MICHAEL'S ELEMENTARY SCHOOL SBHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | ST MICHAELS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216632930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107452882 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 SEYMOUR AVE | ||||||||
| Address2: | |||||||||
| City: | ST. MICHAEL'S | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216632930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107452882 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | RICH | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4104794306 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHOPTANK COMMUNITY HEALTH SYSTEM, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 784381000 | 05 | MD | MEDICAID |