1558333138 NPI number — BROOK LANE HEALTH SERVICES

Table of content: (NPI 1558333138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558333138 NPI number — BROOK LANE HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOK LANE HEALTH SERVICES
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:
ADULT PHP
Provider Other Organization Name Type Code:
5
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:
1558333138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13121 BROOK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-733-0330
Provider Business Mailing Address Fax Number:
301-733-4038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13215 BROOK LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21742-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-733-0330
Provider Business Practice Location Address Fax Number:
301-733-4038
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BISENIEKS
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PHYSICIAN MANAGER
Authorized Official Telephone Number:
301-733-0331

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  3016 , 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: 63503100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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