Healthcare Provider Details

I. General information

NPI: 1659183721
Provider Name (Legal Business Name): SPECIALTY PHYSICIANS OF GARRETT COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GREENE ST
CUMBERLAND MD
21502-2755
US

IV. Provider business mailing address

PO BOX 1647
MORGANTOWN WV
26507-1647
US

V. Phone/Fax

Practice location:
  • Phone: 301-724-7616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LORI DIXON
Title or Position: DIRECTOR, FINANCE
Credential:
Phone: 301-533-4251