Healthcare Provider Details

I. General information

NPI: 1407359532
Provider Name (Legal Business Name): QUEEN ANNE'S MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 REAR DIDONATO DRIVE
CHESTER MD
21619
US

IV. Provider business mailing address

2108 REAR DIDONATO DRIVE
CHESTER MD
21619
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-6205
  • Fax: 410-643-6945
Mailing address:
  • Phone: 410-643-6710
  • Fax: 410-643-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD32036
License Number StateMD

VIII. Authorized Official

Name: DR. GARY JOHN SPROUSE
Title or Position: PHYSICIAN
Credential: MD
Phone: 410-643-6710