Healthcare Provider Details

I. General information

NPI: 1821381427
Provider Name (Legal Business Name): MAPLE GROVE MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 05/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 MAPLE TREE LN
SPRING GROVE VA
23881-8515
US

IV. Provider business mailing address

316 MAPLE TREE LN
SPRING GROVE VA
23881-8515
US

V. Phone/Fax

Practice location:
  • Phone: 804-955-0965
  • Fax:
Mailing address:
  • Phone: 804-955-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101242147
License Number StateVA

VIII. Authorized Official

Name: DR. REBECCA HARDING INGRAM
Title or Position: CEO, PHYSICIAN
Credential: M.D.
Phone: 804-955-0965