=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760031876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATCLINIC PHYSICIANS PRACTICE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 05/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 S DUNDALK AVE STE 400
-----------------------------------------------------
City | DUNDALK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-4273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-220-0780
-----------------------------------------------------
Fax | 410-862-0150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9068
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-0768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-220-0720
-----------------------------------------------------
Fax | 410-862-0150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DANIEL RECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-220-0780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------