MEDICARE: MAPLE GROVE MEDICAL, INC.

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	2084P0800X	Psychiatry Physician	0101242147	VA

General Provider Information

NPI Number	:	1821381427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE GROVE MEDICAL, INC.

Provider Business Mailing Address
First Line	:	316 MAPLE TREE LN
Second Line	:
City	:	SPRING GROVE
State	:	VA
Zip	:	23881-8515
Country	:	US
Telephone Number	:	804-955-0965
Fax Number	:

Provider Business Practice Location Address
First Line	:	316 MAPLE TREE LN
Second Line	:
City	:	SPRING GROVE
State	:	VA
Zip	:	23881-8515
Country	:	US
Telephone Number	:	804-955-0965
Fax Number	:

Authorized Official
Title or Position	:	CEO, PHYSICIAN
Name	:	DR. REBECCA HARDING INGRAM
Credential	:	M.D.
Telephone Number	:	804-955-0965

Provider Enumeration Date	:	05/16/2011
Last Update Date	:	05/16/2011

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