1629471958 NPI number — THE CARE GROUP AT SAFE HARBOR, LLC

Table of content: (NPI 1629471958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629471958 NPI number — THE CARE GROUP AT SAFE HARBOR, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CARE GROUP AT SAFE HARBOR, 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:
1629471958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208 E. CHURCHVILLE ROAD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
BEL AIR
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-893-4600
Provider Business Mailing Address Fax Number:
443-640-4358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208 E CHURCHVILLE RD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21014-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-893-4600
Provider Business Practice Location Address Fax Number:
443-640-4358
Provider Enumeration Date:
10/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SCOGGIN
Authorized Official First Name:
STACI
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
410-893-4600

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3102809 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003403098 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20280710 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q014476 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103054509 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 387081 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 500701703 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 783706200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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