Basic Information
Provider Information | |||||||||
NPI: | 1912039017 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVENTIST HEALTHCARE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVENTIST HEALTHCARE BEHAVIORAL HEALTH & WELLNESS SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 820 W DIAMOND AVE | ||||||||
Address2: | SUITE 500 | ||||||||
City: | GAITHERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 208781419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013153030 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 821 FIELDCREST RD | ||||||||
Address2: |   | ||||||||
City: | CAMBRIDGE | ||||||||
State: | MD | ||||||||
PostalCode: | 216139423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102210288 | ||||||||
FaxNumber: | 4102289588 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2007 | ||||||||
LastUpdateDate: | 08/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEE | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER AND SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 3013153030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   | MD | Y |   | Hospitals | Psychiatric Hospital |   |
No ID Information.