Basic Information
| Provider Information | |||||||||
| NPI: | 1831574284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLY CROSS HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLY CROSS HEALTH LAB OUTREACH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017547000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017547000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | GILLIS | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3017547035 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOLY CROSS HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 035 | MD | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0000435900 | 05 | MD | MEDICAID |