=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679657209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVIDSONVILLE PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2772 RUTLAND RD
-----------------------------------------------------
City | DAVIDSONVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21035-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-269-7828
-----------------------------------------------------
Fax | 410-269-0510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2772 RUTLAND RD
-----------------------------------------------------
City | DAVIDSONVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21035-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE SPECIALIST
-----------------------------------------------------
Name | DIRENDIA SHACKELFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-654-0889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | D0013889
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------