Healthcare Provider Details

I. General information

NPI: 1629815451
Provider Name (Legal Business Name): CALVERTHEALTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL RD STE 213
PRINCE FREDERICK MD
20678-4040
US

IV. Provider business mailing address

100 HOSPITAL RD
PRINCE FREDERICK MD
20678-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-2790
  • Fax: 410-414-2791
Mailing address:
  • Phone: 410-414-4791
  • Fax: 410-535-8417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CAROLYN HEITHAUS
Title or Position: CFO
Credential:
Phone: 410-535-8236