Healthcare Provider Details

I. General information

NPI: 1598956922
Provider Name (Legal Business Name): MANCHESTER FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2973 MANCHESTER RD
MANCHESTER MD
21102-1802
US

IV. Provider business mailing address

2973 MANCHESTER RD
MANCHESTER MD
21102-1802
US

V. Phone/Fax

Practice location:
  • Phone: 410-374-4747
  • Fax: 443-507-0003
Mailing address:
  • Phone: 410-374-4747
  • Fax: 443-507-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BARBARA THOMPSON
Title or Position: BILLING MANAGER
Credential:
Phone: 410-374-4747