Healthcare Provider Details

I. General information

NPI: 1477877215
Provider Name (Legal Business Name): UNIVERSITY OF MARYLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 FIELD HOUSE DR GOSSETT FOOTBALL TEAM HOUSE
COLLEGE PARK MD
20742-0001
US

IV. Provider business mailing address

379 FIELD HOUSE DR GOSSETT FOOTBALL TEAM HOUSE
COLLEGE PARK MD
20742-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-314-2663
  • Fax: 301-314-6549
Mailing address:
  • Phone: 301-314-2663
  • Fax: 301-314-6549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DARRYL CONWAY
Title or Position: ASST. ATHLETIC DIRECTOR
Credential: ATC, EMT-B
Phone: 301-314-2663