Basic Information
| Provider Information | |||||||||
| NPI: | 1992049100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORSICA RIVER MENTAL HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 BANJO LN | ||||||||
| Address2: | P.O. BOX 718 | ||||||||
| City: | CENTREVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216171002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107582211 | ||||||||
| FaxNumber: | 4107581223 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 POPLAR ST | ||||||||
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| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216131834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432255780 | ||||||||
| FaxNumber: | 4432255783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2012 | ||||||||
| LastUpdateDate: | 01/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | PLASKON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4107583050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 4214099 00 | 05 | MD | MEDICAID |