1104802578 NPI number — CAROLINE COUNTY HEALTH DEPARTMENT, DHMH, MD

Table of content: (NPI 1104802578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104802578 NPI number — CAROLINE COUNTY HEALTH DEPARTMENT, DHMH, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINE COUNTY HEALTH DEPARTMENT, DHMH, MD
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:
6
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:
1104802578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 FRANKLIN ST
Provider Second Line Business Mailing Address:
P.O.BOX 10
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21629-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-479-1882
Provider Business Mailing Address Fax Number:
410-479-4918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21629-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-479-1882
Provider Business Practice Location Address Fax Number:
410-479-4918
Provider Enumeration Date:
12/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MALKUS
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
MUMFORD
Authorized Official Title or Position:
PSYCHOLOGIST/PROGRAM ADMINISTRATOR
Authorized Official Telephone Number:
410-479-1882

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  9812 , 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: 9812 . This is a "OUTPATIENT ADDICTION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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