Basic Information
| Provider Information | |||||||||
| NPI: | 1982932208 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WORCESTER COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PSYCHIATRIC REHABILITATION PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | WORCESTER COUNTY HEALTH DEPARTMENT | ||||||||
| City: | SNOW HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106321100 | ||||||||
| FaxNumber: | 4106322476 | ||||||||
| Practice Location | |||||||||
| Address1: | 6040 PUBLIC LANDING ROAD | ||||||||
| Address2: | WORCESTER CO HEALTH DEPT, PSYCHIATRIC REHAB PROGRAM | ||||||||
| City: | SNOW HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106321100 | ||||||||
| FaxNumber: | 4106322476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2009 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARTON | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4106321100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 046850900 | 05 | MD | MEDICAID |