Healthcare Provider Details

I. General information

NPI: 1669960779
Provider Name (Legal Business Name): MEDLINE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11908 MAHER DR
FORT WASHINGTON MD
20744
US

IV. Provider business mailing address

11908 MAHER DR
FORT WASHINGTON MD
20744
US

V. Phone/Fax

Practice location:
  • Phone: 301-235-3026
  • Fax:
Mailing address:
  • Phone: 301-235-3026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALFRED WILLIAM CANNON JR.
Title or Position: CEO
Credential:
Phone: 301-235-3026