Healthcare Provider Details

I. General information

NPI: 1609950146
Provider Name (Legal Business Name): IMMEDIATE CARE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11722 REISTERSTOWN RD
REISTERSTOWN MD
21136-3302
US

IV. Provider business mailing address

11722 REISTERSTOWN RD
REISTERSTOWN MD
21136-3302
US

V. Phone/Fax

Practice location:
  • Phone: 410-833-5000
  • Fax: 410-833-1433
Mailing address:
  • Phone: 410-833-5000
  • Fax: 410-833-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA C NWAOGBO
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-833-5000