Healthcare Provider Details

I. General information

NPI: 1063780633
Provider Name (Legal Business Name): FREDERICK HEALTH MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1562 OPOSSUMTOWN PIKE STE 102
FREDERICK MD
21702-4337
US

IV. Provider business mailing address

501 W 7TH ST
FREDERICK MD
21701-4586
US

V. Phone/Fax

Practice location:
  • Phone: 301-662-8477
  • Fax: 301-668-5793
Mailing address:
  • Phone: 301-662-8477
  • Fax: 301-668-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE K MAHAN
Title or Position: SR. VP AND CFO
Credential:
Phone: 240-566-3355