Healthcare Provider Details

I. General information

NPI: 1295724656
Provider Name (Legal Business Name): MEDICATION ASSISTED TREATMENT TECHNOLOGIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 BRASS MILL ROAD BLDG. A
BELCAMP MD
21017-1213
US

IV. Provider business mailing address

1361 BRASS MILL ROAD BLDG. A
BELCAMP MD
21017-1213
US

V. Phone/Fax

Practice location:
  • Phone: 410-273-9700
  • Fax: 410-273-9713
Mailing address:
  • Phone: 410-273-9700
  • Fax: 410-273-9713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number101202
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number101202
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number12234
License Number StateMD

VIII. Authorized Official

Name: MR. J. CHARLES SMITH JR.
Title or Position: C.E.O., SPONSOR
Credential:
Phone: 410-322-6575