Basic Information
Provider Information | |||||||||
NPI: | 1952367476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMEDOC OF FREDERICK PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 601360 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282601360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432373378 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Practice Location | |||||||||
Address1: | 400 W SEVENTH ST | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217014506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432373378 | ||||||||
FaxNumber: | 8432375073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2006 | ||||||||
LastUpdateDate: | 03/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYNOLDS | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8282103260 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 404823700 | 05 | MD |   | MEDICAID | J585 | 01 | MD | BLUE SHIELD FEDERAL | OTHER | 633APR | 01 | MD | BLUE SHIELD STATE | OTHER | 136915 | 01 | VA | BCBS | OTHER | DB5153 | 01 | MD | RAILROAD MEDICARE | OTHER |