Provider Demographics
NPI:1124579875
Name:PRINCE GEORGES COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:PRINCE GEORGES COUNTY HEALTH DEPARTMENT
Other - Org Name:NORTHERN REGION - OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-883-7822
Mailing Address - Street 1:3003 HOSPITAL DR
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1194
Mailing Address - Country:US
Mailing Address - Phone:301-583-5920
Mailing Address - Fax:301-583-5950
Practice Address - Street 1:3003 HOSPITAL DR
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1194
Practice Address - Country:US
Practice Address - Phone:301-583-5920
Practice Address - Fax:301-583-5950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCE GEORGES COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-18
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10839445125OtherOTHER NPI - TYPE 50