=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114198835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YDIPRMC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 01/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 N SALISBURY BLVD
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-222-4934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 327 TILGHMAN RD STE 200
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-210-2542
-----------------------------------------------------
Fax | 410-334-6352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | MARIA A CORNMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-944-3351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 20235706
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------