1962173708 NPI number — MS. BLYTHE ELIZABETH EBERLE CRNM

Table of content: MS. BLYTHE ELIZABETH EBERLE CRNM (NPI 1962173708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962173708 NPI number — MS. BLYTHE ELIZABETH EBERLE CRNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBERLE
Provider First Name:
BLYTHE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRZEKOP
Provider Other First Name:
BLYTHE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962173708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1978
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21802-1978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-749-1015
Provider Business Mailing Address Fax Number:
410-749-0654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1647 WOODBROOKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804-8502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-546-2424
Provider Business Practice Location Address Fax Number:
410-742-6633
Provider Enumeration Date:
09/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  R219419 , 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: 119591300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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