1174019327 NPI number — OWENSVILLE PRIMARY CARE, INC

Table of content: STEPHANIE LYNN BERRY (NPI 1952988123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174019327 NPI number — OWENSVILLE PRIMARY CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OWENSVILLE PRIMARY CARE, INC
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:
1174019327
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
134 OWENSVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20778-9702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-867-4700
Provider Business Mailing Address Fax Number:
410-867-4934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6131 SHADY SIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHADY SIDE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20764-9504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-867-2200
Provider Business Practice Location Address Fax Number:
410-867-1261
Provider Enumeration Date:
07/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
VARGA
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
REVENUE CYCLE MANAGER
Authorized Official Telephone Number:
410-867-4700

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X , with the licence number:  LC0431 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: H78924 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: D0038563 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0901X , with the licence number: H0076407 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: C0003844 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: R124971 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 97991100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063914836 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209002300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 338427600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 400629100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 404482700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103559201 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 531981100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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