1174893556 NPI number — QUEEN ANNE'S COUNTY HEALTH DEPARTMENT

Table of content: (NPI 1174893556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174893556 NPI number — QUEEN ANNE'S COUNTY HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUEEN ANNE'S COUNTY HEALTH DEPARTMENT
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:
1174893556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N COMMERCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTREVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21617-1049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-758-1306
Provider Business Mailing Address Fax Number:
410-758-2133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 N LIBERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTREVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21617-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-758-1306
Provider Business Practice Location Address Fax Number:
410-758-2133
Provider Enumeration Date:
01/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FRY
Authorized Official First Name:
GARY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
410-758-1306

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  750325 , 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: 420917600 . This is a "JAI MEDICAL MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 . This is a "UNITED HEALTH CARE-MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 01372281 . This is a "AMERIGROUP MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 . This is a "MARYLAND PHYSICIANS CARE MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 019364 . This is a "RIVERSIDE MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 019364 . This is a "VALUE OPTIONS MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 056064 . This is a "PRIORITY PARTNERS PAC MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: H93 . This is a "CAREFIRST BCBS OF MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 01372281 . This is a "AMERIGROUP PAC MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 . This is a "DIAMOND PLAN MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 . This is a "UNITED BEHAVIORAL HEALTH MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 056064 . This is a "PRIORITY PARTNERS MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 . This is a "MEDSTAR FAMILY MA MCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 420917600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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