Healthcare Provider Details

I. General information

NPI: 1841002102
Provider Name (Legal Business Name): SPECIALTY PHYSICIANS OF GARRETT COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 CORPORATE DR
GRANTSVILLE MD
21536-1259
US

IV. Provider business mailing address

PO BOX 1647
MORGANTOWN WV
26507-1647
US

V. Phone/Fax

Practice location:
  • Phone: 301-895-8750
  • Fax: 301-895-8751
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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