1194085928 NPI number — ALDON

Table of content: (NPI 1194085928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194085928 NPI number — ALDON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALDON
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:
1194085928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8955 EDMONSTON RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
GREENBELT
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20770-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-667-4290
Provider Business Mailing Address Fax Number:
240-539-0216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7105 PONY TRAIL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HYATTSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20782-1031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-667-4290
Provider Business Practice Location Address Fax Number:
240-539-0216
Provider Enumeration Date:
05/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ARNASONBRAXTONA
Authorized Official First Name:
PHYLLIS
Authorized Official Middle Name:
BRAXTON
Authorized Official Title or Position:
PRESIDENT, CLINICAL DIRECTOR
Authorized Official Telephone Number:
240-667-4290

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: YA2928 . This is a "ANTHEM EAP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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