1457885709 NPI number — SOUTHERN MARYLAND COMMUNITY NETWORK, INC.

Table of content: NICHOLAS SCOTT DOLEZAL PT, DPT (NPI 1003587270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457885709 NPI number — SOUTHERN MARYLAND COMMUNITY NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MARYLAND COMMUNITY NETWORK, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457885709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 998
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-0998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-535-4787
Provider Business Mailing Address Fax Number:
410-535-4965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2670 CRAIN HWY
Provider Second Line Business Practice Location Address:
SUITE #505
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20601-2806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-932-9146
Provider Business Practice Location Address Fax Number:
301-932-9361
Provider Enumeration Date:
04/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CARLONI
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
410-535-4787

Provider Taxonomy Codes

  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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