1619411121 NPI number — FREDERICK PSYCHIATRIC MEDICINE

Table of content: (NPI 1619411121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619411121 NPI number — FREDERICK PSYCHIATRIC MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREDERICK PSYCHIATRIC MEDICINE
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:
1619411121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10001 PEBBLE BEACH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IJAMSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21754-9147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-606-7785
Provider Business Mailing Address Fax Number:
240-310-1927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10001 PEBBLE BEACH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IJAMSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21754-9147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-606-7785
Provider Business Practice Location Address Fax Number:
240-310-1927
Provider Enumeration Date:
12/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ROBINSON
Authorized Official First Name:
CORVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-606-7785

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  DOO44857 , 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: 60054 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: MDMCD , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00823 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: SKMDO , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: SB580 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: D0044857 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: SX173 . This is a "BEACON HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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