Healthcare Provider Details

I. General information

NPI: 1104135268
Provider Name (Legal Business Name): WALNUT STREET COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S CLEVELAND AVE
HAGERSTOWN MD
21740-5745
US

IV. Provider business mailing address

201 S CLEVELAND AVE
HAGERSTOWN MD
21740-5745
US

V. Phone/Fax

Practice location:
  • Phone: 301-745-3777
  • Fax: 301-393-3463
Mailing address:
  • Phone: 301-745-3777
  • Fax: 301-393-3463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number13994
License Number StateMD

VIII. Authorized Official

Name: ANGELA MUNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-745-3777