Healthcare Provider Details

I. General information

NPI: 1851752513
Provider Name (Legal Business Name): YDIPRMC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SUNBURST HWY
CAMBRIDGE MD
21613-2506
US

IV. Provider business mailing address

327 TILGHMAN RD STE 200
SALISBURY MD
21804-2015
US

V. Phone/Fax

Practice location:
  • Phone: 443-477-6324
  • Fax: 410-334-6352
Mailing address:
  • Phone: 443-944-3351
  • Fax: 410-334-6352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA A CORNMAN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 443-944-3351