Healthcare Provider Details

I. General information

NPI: 1932388493
Provider Name (Legal Business Name): SOUTH MOUNTAIN COMMUNITY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAINT PAUL ST STE 3
BOONSBORO MD
21713
US

IV. Provider business mailing address

9 SAINT PAUL ST 2ND FLOOR
BOONSBORO MD
21713-1334
US

V. Phone/Fax

Practice location:
  • Phone: 301-432-6897
  • Fax: 301-432-6298
Mailing address:
  • Phone: 301-432-6897
  • Fax: 301-432-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR100650
License Number StateMD

VIII. Authorized Official

Name: MS. TRACEY GALLOWAY ELIZALDE
Title or Position: OWNER
Credential: CRNP
Phone: 301-432-6897