Healthcare Provider Details

I. General information

NPI: 1144092412
Provider Name (Legal Business Name): ST. MARY'S EVERSIDE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23000 MOAKLEY ST STE 202
LEONARDTOWN MD
20650-2917
US

IV. Provider business mailing address

1400 WEWATTA ST STE 350
DENVER CO
80202-5553
US

V. Phone/Fax

Practice location:
  • Phone: 704-661-1380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546