Provider Demographics
NPI:1073385613
Name:PORT RECOVERY IOP INC.
Entity Type:Organization
Organization Name:PORT RECOVERY IOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-869-4909
Mailing Address - Street 1:8615 RIDGELYS CHOICE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3028
Mailing Address - Country:US
Mailing Address - Phone:434-869-4909
Mailing Address - Fax:443-869-4928
Practice Address - Street 1:2917 BAYONNE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1726
Practice Address - Country:US
Practice Address - Phone:443-869-4909
Practice Address - Fax:443-869-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6800271Medicaid
MD6800297Medicaid
MD6804021Medicaid