MEDICARE: AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC

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	261QH0100X	Health Service Clinic/Center
2	207QA0000X	Adolescent Medicine (Family Medicine) Physician

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457956948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	4367 HOLLINS FERRY RD STE 1C
Second Line	:
City	:	HALETHORPE
State	:	MD
Zip	:	21227-3400
Country	:	US
Telephone Number	:	410-609-6677
Fax Number	:	410-609-6672

Provider Business Practice Location Address
First Line	:	4367 HOLLINS FERRY RD STE 1C
Second Line	:
City	:	HALETHORPE
State	:	MD
Zip	:	21227-3400
Country	:	US
Telephone Number	:	410-609-6677
Fax Number	:	410-609-6672

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. JACQUELINE EBONY AMBUSH
Credential	:	DNP
Telephone Number	:	410-707-5947

Provider Enumeration Date	:	12/02/2020
Last Update Date	:	04/07/2026

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Directions to “AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC ” Practice Location

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