Healthcare Provider Details

I. General information

NPI: 1124579875
Provider Name (Legal Business Name): PRINCE GEORGES COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HOSPITAL DR GROUND FLOOR
CHEVERLY MD
20785-1194
US

IV. Provider business mailing address

3003 HOSPITAL DR GROUND FLOOR
CHEVERLY MD
20785-1194
US

V. Phone/Fax

Practice location:
  • Phone: 301-583-5920
  • Fax: 301-583-5950
Mailing address:
  • Phone: 301-583-5920
  • Fax: 301-583-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TAMALA BUTLER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 301-883-7822