1477554129 NPI number — PROFESSIONAL EMERGENCY PHYSICIAN SERVICES, LLC

Table of content: (NPI 1477554129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477554129 NPI number — PROFESSIONAL EMERGENCY PHYSICIAN SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL EMERGENCY PHYSICIAN SERVICES, LLC
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:
1477554129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21550-4597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-533-4201
Provider Business Mailing Address Fax Number:
301-533-4208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 N FOURTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21550-1375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-533-4201
Provider Business Practice Location Address Fax Number:
301-533-4208
Provider Enumeration Date:
08/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LIPSCOMB
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
VIP FINANCE/CFO
Authorized Official Telephone Number:
301-533-4201

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 777A . This is a "BLUE CROSS CONSOL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 777A . This is a "B/C GENERAL MOTORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: MA6 . This is a "B/C FEDERAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 777A . This is a "B/C MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: J748 . This is a "BLUE CROSS EMPIRE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407145000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 777A . This is a "B/C MT STATE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 777A . This is a "CAREFIRST B/C" identifier . This identifiers is of the category "OTHER".
  • Identifier: 777A . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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