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

Table of Contents

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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