1952367476 NPI number — PRIMEDOC OF FREDERICK PA

Table of content: (NPI 1952367476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952367476 NPI number — PRIMEDOC OF FREDERICK PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMEDOC OF FREDERICK PA
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:
1952367476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-1360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-237-3378
Provider Business Mailing Address Fax Number:
843-237-5073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W SEVENTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701-4506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-237-3378
Provider Business Practice Location Address Fax Number:
843-237-5073
Provider Enumeration Date:
04/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-210-3260

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 404823700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: J585 . This is a "BLUE SHIELD FEDERAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 633APR . This is a "BLUE SHIELD STATE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 136915 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DB5153 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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