Basic Information
| Provider Information | |||||||||
| NPI: | 1881096261 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL SERVICES OF HOLY CROSS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOLY CROSS HEALTH PARTNERS AT ASBURY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17112 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432742900 | ||||||||
| FaxNumber: | 4432742391 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 RUSSELL AVE | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015572110 | ||||||||
| FaxNumber: | 3015572120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRINTZ | ||||||||
| AuthorizedOfficialFirstName: | MARLENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3015571888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOLY CROSS HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 4097289 | 05 | MD | MEDICAID |