Healthcare Provider Details

I. General information

NPI: 1386871390
Provider Name (Legal Business Name): CALVERTHEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL ROAD
PRINCE FREDERICK MD
20678-4017
US

IV. Provider business mailing address

100 HOSPITAL ROAD
PRINCE FREDERICK MD
20678-4017
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-8248
  • Fax: 410-535-8417
Mailing address:
  • Phone: 410-535-8248
  • 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 Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

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