Healthcare Provider Details

I. General information

NPI: 1487844593
Provider Name (Legal Business Name): SOUTH MOUNTAIN FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAINT PAUL ST
BOONSBORO MD
21713-1334
US

IV. Provider business mailing address

9 SAINT PAUL ST
BOONSBORO MD
21713-1334
US

V. Phone/Fax

Practice location:
  • Phone: 301-432-0623
  • Fax: 301-432-0624
Mailing address:
  • Phone: 301-432-0623
  • Fax: 301-432-0624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD0056826
License Number StateMD

VIII. Authorized Official

Name: DR. WILLIAM F BODENHEIMER III
Title or Position: OWNER
Credential: MD
Phone: 301-432-0623