=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588974471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK PORTER DOUGHERTY PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2010
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 EAST CARROLL ST PENINSULA REGIONAL MEDICAL CENTER
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-912-5697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 ERICA CT
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-7419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-229-8983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 18802
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------