=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194375089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCK CREEK HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2019
-----------------------------------------------------
Last Update Date | 09/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1682 E GUDE DR STE 304
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-5314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-969-1616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1682 E GUDE DR STE 304
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-5314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT AGENT
-----------------------------------------------------
Name | ANDRE GLIGOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-969-1616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------