Healthcare Provider Details

I. General information

NPI: 1568109189
Provider Name (Legal Business Name): MEADOWRIDGE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 MEADOWRIDGE CENTER DR STE P1
ELKRIDGE MD
21075-6528
US

IV. Provider business mailing address

6020 MEADOWRIDGE CENTER DR STE P1
ELKRIDGE MD
21075-6528
US

V. Phone/Fax

Practice location:
  • Phone: 443-936-8821
  • Fax:
Mailing address:
  • Phone: 443-492-9466
  • 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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CELINE CHANG
Title or Position: NURSE PRACTITIONER/OWNER
Credential: CPNP-PC
Phone: 443-492-9466