Healthcare Provider Details

I. General information

NPI: 1255573853
Provider Name (Legal Business Name): PENINSUAL REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10514 RACETRACK RD STE C OCEAN PINES FAMILY MEDICINE
BERLIN MD
21811-3241
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-8585
  • Fax: 410-641-6616
Mailing address:
  • Phone: 410-543-7252
  • Fax: 410-912-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA E HORNER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 410-543-7531