Healthcare Provider Details

I. General information

NPI: 1972114403
Provider Name (Legal Business Name): ERICKSON HEALTH MEDICAL GROUP OF MARYLAND, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 MAIDEN CHOICE LN
CATONSVILLE MD
21228-3632
US

IV. Provider business mailing address

PO BOX 783712
PHILADELPHIA PA
19178-3712
US

V. Phone/Fax

Practice location:
  • Phone: 410-247-5602
  • Fax: 410-242-1756
Mailing address:
  • Phone: 800-360-3851
  • Fax: 410-402-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DONNA ETHEL RACHUBA
Title or Position: MEDICAL STAFF SERVICES DIRECTOR
Credential:
Phone: 410-402-2258