Provider Demographics
NPI:1033542279
Name:WESTERN MARYLAND HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:WESTERN MARYLAND HEALTH SYSTEM CORPORATION
Other - Org Name:DIABETIC OUTPATIENT COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-964-8342
Mailing Address - Street 1:12500 WILLOWBROOK RD
Mailing Address - Street 2:3RD FLOOR, BUSINESS OFFICE
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6393
Mailing Address - Country:US
Mailing Address - Phone:240-964-8342
Mailing Address - Fax:240-964-8337
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:240-964-8342
Practice Address - Fax:240-964-8337
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN MARYLAND HEALTH SYSTEM CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01-007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty