Basic Information
| Provider Information | |||||||||
| NPI: | 1982618617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY CARE OF EASTON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8579 COMMERCE DRIVE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108190404 | ||||||||
| FaxNumber: | 4108190751 | ||||||||
| Practice Location | |||||||||
| Address1: | 8579 COMMERCE DRIVE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216017420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108190404 | ||||||||
| FaxNumber: | 4108190751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | DELEAN-BOTKIN | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4108190404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 404025200 | 05 | MD | MEDICAID | DB0501 | 01 | MD | RAILROAD MEDICARE | OTHER |