Healthcare Provider Details

I. General information

NPI: 1457956948
Provider Name (Legal Business Name): AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4367 HOLLINS FERRY RD STE 1C
HALETHORPE MD
21227-3400
US

IV. Provider business mailing address

4367 HOLLINS FERRY RD STE 1C
HALETHORPE MD
21227-3400
US

V. Phone/Fax

Practice location:
  • Phone: 410-609-6677
  • Fax: 410-609-6672
Mailing address:
  • Phone: 410-609-6677
  • Fax: 410-609-6672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELINE EBONY AMBUSH
Title or Position: OWNER/OPERATOR
Credential: DNP
Phone: 410-707-5947