Healthcare Provider Details

I. General information

NPI: 1083297089
Provider Name (Legal Business Name): MEDITELECARE OF MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SAINT PAUL ST STE 820
BALTIMORE MD
21202-1681
US

IV. Provider business mailing address

PO BOX 1595
MIDDLETOWN CT
06457-8095
US

V. Phone/Fax

Practice location:
  • Phone: 860-788-6404
  • Fax: 860-829-0495
Mailing address:
  • Phone: 860-788-6404
  • Fax: 860-829-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA GODFREY
Title or Position: CREDENTIALING & ENROLLMENT MANAGER
Credential:
Phone: 860-398-6441