1336296730 NPI number — MED-PED HEALTH CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336296730 NPI number — MED-PED HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-PED HEALTH CARE LLC
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:
1336296730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6201 GREENBELT RD
Provider Second Line Business Mailing Address:
SUITE M-16
Provider Business Mailing Address City Name:
BERWYN HEIGHTS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20740-2354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-441-4400
Provider Business Mailing Address Fax Number:
301-441-3008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6201 GREENBELT RD
Provider Second Line Business Practice Location Address:
SUITE M16
Provider Business Practice Location Address City Name:
BERWYN HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20740-2354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-441-4400
Provider Business Practice Location Address Fax Number:
301-441-3008
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FADUL
Authorized Official First Name:
JAMAL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
301-441-4400

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; 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: 0062057 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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