Basic Information
| Provider Information | |||||||||
| NPI: | 1841702180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERY ROAD COMBINED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9701 KEYSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EMMITSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217278619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014472361 | ||||||||
| FaxNumber: | 3014473715 | ||||||||
| Practice Location | |||||||||
| Address1: | 14701 AVERY RD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208533605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012798828 | ||||||||
| FaxNumber: | 3012798910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FISHMAN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4102331400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 905577 | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.