1982005237 NPI number — CH MD SOUTHERN COLLABORATIVE CARE PC

Table of content: (NPI 1982005237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982005237 NPI number — CH MD SOUTHERN COLLABORATIVE CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CH MD SOUTHERN COLLABORATIVE CARE PC
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:
1982005237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4055 VALLEY VIEW LN
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-715-3800
Provider Business Mailing Address Fax Number:
888-722-4282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 OXFORD SHIRE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20603-3215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
667-207-7006
Provider Business Practice Location Address Fax Number:
888-722-4282
Provider Enumeration Date:
09/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
COOKE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
972-715-3808

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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