Provider Demographics
NPI:1003693102
Name:ANTIETAM FAMILY HEALTH, LLC
Entity Type:Organization
Organization Name:ANTIETAM FAMILY HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:RONCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-203-8864
Mailing Address - Street 1:1101 OPAL CT STE 217
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5941
Mailing Address - Country:US
Mailing Address - Phone:240-203-8864
Mailing Address - Fax:
Practice Address - Street 1:221 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6109
Practice Address - Country:US
Practice Address - Phone:240-203-8864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty