MEDICARE: ST. AUGUSTIN HEALTHCARE INC

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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1295664670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. AUGUSTIN HEALTHCARE INC

Provider Business Mailing Address
First Line	:	9105 JOUSTING LN
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4388
Country	:	US
Telephone Number	:	240-872-6598
Fax Number	:

Provider Business Practice Location Address
First Line	:	9105 JOUSTING LN
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4388
Country	:	US
Telephone Number	:	240-872-6598
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BASIL TEGHEN NDUM
Credential	:
Telephone Number	:	240-872-6598

Provider Enumeration Date	:	05/14/2026
Last Update Date	:	05/31/2026

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