Healthcare Provider Details

I. General information

NPI: 1508163320
Provider Name (Legal Business Name): ST. MARY'S HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21580 PEABODY ST
LEONARDTOWN MD
20650-2962
US

IV. Provider business mailing address

21580 PEABODY ST
LEONARDTOWN MD
20650-2962
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-4330
  • Fax: 301-475-4383
Mailing address:
  • Phone: 301-475-4330
  • Fax: 301-475-4383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License NumberR096847
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberR096847
License Number StateMD

VIII. Authorized Official

Name: MR. MICHAEL WAYNE BRIDGETT I
Title or Position: CRNP
Credential: CRNP
Phone: 301-475-4330