MEDICARE: WALDORF INTEGRATED HEALTHCARE, LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1609844018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALDORF INTEGRATED HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1565
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20604-1565
Country	:	US
Telephone Number	:	301-645-9551
Fax Number	:	301-645-0039

Provider Business Practice Location Address
First Line	:	29015 THREE NOTCH RD
Second Line	:	SUITE 1-A
City	:	MECHANICSVILLE
State	:	MD
Zip	:	20659-3228
Country	:	US
Telephone Number	:	301-290-5285
Fax Number	:	301-290-5287

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JOAN BARKER
Credential	:	CMM
Telephone Number	:	301-645-9551

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	10/26/2007

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