Basic Information
Provider Information | |||||||||
NPI: | 1992224497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SILVER SPRING HEALTH CARE MANAGEMENT, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SCMG NURSERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 229 | ||||||||
Address2: |   | ||||||||
City: | WAKEFIELD | ||||||||
State: | RI | ||||||||
PostalCode: | 028800229 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017888757 | ||||||||
FaxNumber: | 4017829867 | ||||||||
Practice Location | |||||||||
Address1: | 100 KENYON AVE | ||||||||
Address2: |   | ||||||||
City: | WAKEFIELD | ||||||||
State: | RI | ||||||||
PostalCode: | 028794216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017828000 | ||||||||
FaxNumber: | 4017883958 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2017 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POLHEMUS | ||||||||
AuthorizedOfficialFirstName: | MARCIA | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4017881974 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 174400000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   | 2080A0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LN0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.