Healthcare Provider Details

I. General information

NPI: 1699385336
Provider Name (Legal Business Name): MATCLINIC PHYSICIANS PRACTICE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 YORK RD STE 201
TOWSON MD
21204-5243
US

IV. Provider business mailing address

PO BOX 9068
BALTIMORE MD
21222-0768
US

V. Phone/Fax

Practice location:
  • Phone: 410-220-0780
  • Fax: 410-862-0150
Mailing address:
  • Phone: 410-220-0720
  • Fax: 410-862-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier661011103
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 2
Identifier200710013
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerDEPT OF HEALTH, BEHAVIORAL HEALTH ADMIN

VIII. Authorized Official

Name: DAN RECK
Title or Position: MANAGER
Credential:
Phone: 410-220-0780