=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891510707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK PEDIATRIC ASSOCIATES P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6550 MERCANTILE DR E STE 106
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21703-7656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-668-6347
-----------------------------------------------------
Fax | 301-668-9780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 87 THOMAS JOHNSON DR STE 101
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-694-0606
-----------------------------------------------------
Fax | 877-276-4919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MARY JARVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-694-0606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------