Healthcare Provider Details

I. General information

NPI: 1902232168
Provider Name (Legal Business Name): MEDICAL HOME DEVELOPMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 BENNING RD NE SUITE 200
WASHINGTON DC
20002-4569
US

IV. Provider business mailing address

4975 LACROSS RD SUITE 153
N CHARLESTON SC
29406-6523
US

V. Phone/Fax

Practice location:
  • Phone: 843-412-5548
  • Fax: 866-643-9237
Mailing address:
  • Phone: 843-412-5548
  • Fax: 866-643-9237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics
License NumberSCLN12893
License Number StateSC

VIII. Authorized Official

Name: MRS. AUDREY WHETSELL
Title or Position: CEO
Credential: MS
Phone: 843-412-5548