=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801235015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK HEALTH MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2013
-----------------------------------------------------
Last Update Date | 02/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 THOMAS JOHNSON DR
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-695-3100
-----------------------------------------------------
Fax | 240-575-2527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 194 THOMAS JOHNSON DR
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-575-2526
-----------------------------------------------------
Fax | 240-575-2527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO AND SR. VP
-----------------------------------------------------
Name | MS. MICHELLE K MAHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-566-3355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085D0003X
-----------------------------------------------------
Taxonomy Name | Diagnostic Neuroimaging (Radiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2085U0001X
-----------------------------------------------------
Taxonomy Name | Diagnostic Ultrasound Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2355A2700X
-----------------------------------------------------
Taxonomy Name | Audiology Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 2471C3401X
-----------------------------------------------------
Taxonomy Name | Computed Tomography Radiologic Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2471M1202X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging Radiologic Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------