MEDICARE: 6812 MCCORMICK RD. UPPER MARLBORO MD. 20772

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	R3967	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326588112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	6812 MCCORMICK RD. UPPER MARLBORO MD. 20772

Provider Business Mailing Address
First Line	:	6812 MCCORMICK RD
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4351
Country	:	US
Telephone Number	:	240-274-4794
Fax Number	:

Provider Business Practice Location Address
First Line	:	6812 MCCORMICK RD
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4351
Country	:	US
Telephone Number	:	240-274-4794
Fax Number	:

Authorized Official
Title or Position	:	DON
Name	:	MRS. FIDELIA YAA TUFUOR
Credential	:
Telephone Number	:	240-274-4794

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	02/28/2017

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