1801898002 NPI number — DR. JARL THOMAS WATHNE M. D.

Table of content: (NPI 1346423191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801898002 NPI number — DR. JARL THOMAS WATHNE M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATHNE
Provider First Name:
JARL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M. D.
Provider Gender Code:
M

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:
1801898002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11110 MEDICAL CAMPUS RD
Provider Second Line Business Mailing Address:
STE 126
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-6799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-714-4375
Provider Business Mailing Address Fax Number:
301-714-4365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11110 MEDICAL CAMPUS RD
Provider Second Line Business Practice Location Address:
STE 126
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21742-6799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-714-4375
Provider Business Practice Location Address Fax Number:
301-714-4365
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  D0046383 , 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: 148591100 793251101 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 53302402 S186 . This is a "CAREFIRST BS IND & GRP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 516773 GRP 593934 . This is a "PA BS PA LOCATION" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0005 H883 . This is a "CAREFIRST REGIONAL NTWRK" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2172963 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 516615 GRP 59855 . This is a "PA BS MD LOCATION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 50002834 GP 02426700 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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