MEDICARE: PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP0905X	State or Local Public Health Clinic/Center
2	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1265920615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT

Provider Business Mailing Address
First Line	:	1701 MCCORMICK DR STE 120
Second Line	:
City	:	LARGO
State	:	MD
Zip	:	20774-5329
Country	:	US
Telephone Number	:	301-883-7822
Fax Number	:	301-883-7890

Provider Business Practice Location Address
First Line	:	6501 COLUMBIA PARK RD
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-3970
Country	:	US
Telephone Number	:	240-573-7255
Fax Number	:	301-883-7890

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	TAMALA BUTLER
Credential	:
Telephone Number	:	301-883-7822

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	09/17/2020

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