=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578262143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMISE HEALTH OF MARYLAND MEDICAL P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2023
-----------------------------------------------------
Last Update Date | 03/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16305 ELLIOTT PARKWAY
-----------------------------------------------------
City | WILLIAMSPORT
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-313-3818
-----------------------------------------------------
Fax | 240-673-3823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEGAL COUNSEL
-----------------------------------------------------
Name | WILLIAM WRIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-577-5893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------