=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063147395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND ELDER CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2022
-----------------------------------------------------
Last Update Date | 07/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2131 DAVIDSONVILLE RD
-----------------------------------------------------
City | CROFTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21114-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-507-7617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 542 FAIRMOUNT RD
-----------------------------------------------------
City | LINTHICUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21090-2842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-995-7439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEGAN GREY
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 410-995-7439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------