1790114056 NPI number — ADVANTAGE PSYCHIATRIC SERVICES LLC

Table of content: (NPI 1790114056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790114056 NPI number — ADVANTAGE PSYCHIATRIC SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE PSYCHIATRIC SERVICES 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:
1790114056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5024 CAMPBELL BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NOTTINGHAM
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21236-5974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-686-3629
Provider Business Mailing Address Fax Number:
410-780-7178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5024 CAMPBELL BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NOTTINGHAM
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21236-5974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-686-3629
Provider Business Practice Location Address Fax Number:
410-780-7178
Provider Enumeration Date:
11/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PIXTON
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
410-686-3629

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  4607 , 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: 4607 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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