Healthcare Provider Details

I. General information

NPI: 1487018180
Provider Name (Legal Business Name): EBH NORTHEAST SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 IRON RIDGE RD
HANOVER PA
17331-6838
US

IV. Provider business mailing address

PO BOX 670600
DALLAS TX
75267-0600
US

V. Phone/Fax

Practice location:
  • Phone: 615-567-7256
  • Fax:
Mailing address:
  • Phone: 615-567-7256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberOS009643L
License Number StatePA

VIII. Authorized Official

Name: CHERYL MAPLESDEN
Title or Position: DIRECTOR, REVENUE CYCLE
Credential: CPC, CHC, CHPC
Phone: 615-510-3708