Healthcare Provider Details

I. General information

NPI: 1679927982
Provider Name (Legal Business Name): LOWER SHORE IMMEDIATE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12302 SOMERSET AVE SUITE A/B
PRINCESS ANNE MD
21853-3099
US

IV. Provider business mailing address

12302 SOMERSET AVE SUITE A/B
PRINCESS ANNE MD
21853-3099
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-0300
  • Fax: 302-947-4433
Mailing address:
  • Phone: 410-651-0300
  • Fax: 302-947-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM FROCK
Title or Position: CONTRACTING AND CREDENTIALING
Credential:
Phone: 605-789-6661