Basic Information
Provider Information | |||||||||
NPI: | 1942360490 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACHD-LOIS E. JACKSON UNIT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1745 | ||||||||
Address2: |   | ||||||||
City: | CUMBERLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215011745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017595000 | ||||||||
FaxNumber: | 3017775674 | ||||||||
Practice Location | |||||||||
Address1: | 10102 COUNTRY CLUB RD SE | ||||||||
Address2: |   | ||||||||
City: | CUMBERLAND | ||||||||
State: | MD | ||||||||
PostalCode: | 215028339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017772290 | ||||||||
FaxNumber: | 3017772141 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 08/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAVER | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3017595001 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ALLEGANY COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD, MPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 16297 | MD | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
ID Information
ID | Type | State | Issuer | Description | 055998 | 01 |   | PRIORITY PARTNERS (MCO) | OTHER | 02IO | 01 |   | MAGELLAN | OTHER | 351541 | 01 |   | MAMSI | OTHER | 603304100 | 05 | MD |   | MEDICAID | 5098907 | 01 |   | UBH (MCO) | OTHER | IO | 01 |   | MAGELLAN | OTHER | 323817 | 01 |   | VALUE OPTIONS | OTHER | NU1 | 01 |   | GHMSI | OTHER | 277593 | 01 |   | MAMSI | OTHER | 604116-02 | 01 |   | CAREFIRST BCBS | OTHER |