1295724656 NPI number — MEDICATION ASSISTED TREATMENT TECHNOLOGIES, INC

Table of content: (NPI 1295724656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295724656 NPI number — MEDICATION ASSISTED TREATMENT TECHNOLOGIES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICATION ASSISTED TREATMENT TECHNOLOGIES, 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:
MATT PROGRAM
Provider Other Organization Name Type Code:
3
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:
1295724656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1361 BRASS MILL ROAD
Provider Second Line Business Mailing Address:
BLDG. A
Provider Business Mailing Address City Name:
BELCAMP
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21017-1213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-273-9700
Provider Business Mailing Address Fax Number:
410-273-9713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1361 BRASS MILL ROAD
Provider Second Line Business Practice Location Address:
BLDG. A
Provider Business Practice Location Address City Name:
BELCAMP
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21017-1213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-273-9700
Provider Business Practice Location Address Fax Number:
410-273-9713
Provider Enumeration Date:
10/18/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
J.
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
C.E.O., SPONSOR
Authorized Official Telephone Number:
410-322-6575

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  101202 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: 101202 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: 12234 , 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: 0019661780001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4034538-00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 403453800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".