Healthcare Provider Details

I. General information

NPI: 1396898128
Provider Name (Legal Business Name): STATE OF MARYLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SOLOMONS ISLAND RD N
PRINCE FREDERICK MD
20678-0980
US

IV. Provider business mailing address

PO BOX 980 975 SOLOMONS ISLAND RD NORTH
PRINCE FREDERICK MD
20678-0980
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5400
  • Fax: 410-535-5285
Mailing address:
  • Phone: 410-535-5400
  • Fax: 410-535-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberD10879
License Number StateMD

VIII. Authorized Official

Name: DR. DAVID L ROGERS
Title or Position: HEALTH OFFICER
Credential: M.D., M.P.H.
Phone: 410-535-5400