=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457956948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2020
-----------------------------------------------------
Last Update Date | 12/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4367 HOLLINS FERRY RD STE 1C
-----------------------------------------------------
City | HALETHORPE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21227-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-609-6677
-----------------------------------------------------
Fax | 410-609-6672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11610 CLARKSVILLE PIKE
-----------------------------------------------------
City | ELLICOTT CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21042-6142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-609-6677
-----------------------------------------------------
Fax | 410-609-6672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | DR. JACQUELINE EBONY AMBUSH
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 410-707-5947
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------