Healthcare Provider Details

I. General information

NPI: 1245740109
Provider Name (Legal Business Name): 75TH STREET INJURY & ILLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7408 COASTAL HWY
OCEAN CITY MD
21842-2936
US

IV. Provider business mailing address

12547 OCEAN GTWY
OCEAN CITY MD
21842-9689
US

V. Phone/Fax

Practice location:
  • Phone: 410-524-0075
  • Fax:
Mailing address:
  • Phone: 410-213-0119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA W RANDOLPH
Title or Position: ADMINISTRATOR
Credential: PA-C
Phone: 410-524-0075