Healthcare Provider Details

I. General information

NPI: 1194213728
Provider Name (Legal Business Name): PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 57TH AVE
BLADENSBURG MD
20710-1710
US

IV. Provider business mailing address

1701 MCCORMICK DR STE 120
LARGO MD
20774-5329
US

V. Phone/Fax

Practice location:
  • Phone: 240-696-3356
  • Fax: 301-883-7890
Mailing address:
  • Phone: 301-883-7822
  • Fax: 301-883-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMALA BUTLER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 301-883-7822