Basic Information
| Provider Information | |||||||||
| NPI: | 1780627810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANTIETAM PEDIATRIC AND ADOLESCENT CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 OMEGA DR | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013932600 | ||||||||
| FaxNumber: | 2103932614 | ||||||||
| Practice Location | |||||||||
| Address1: | 1161 OMEGA DR | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013932600 | ||||||||
| FaxNumber: | 2103932614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | LEON | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3013932600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.