Provider Demographics
NPI:1194213728
Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Other - Org Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT-SBW-BLADENSBURG
Other - Org Type:Other Name
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 1:1701 MCCORMICK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5329
Mailing Address - Country:US
Mailing Address - Phone:301-883-7822
Mailing Address - Fax:301-883-7890
Practice Address - Street 1:4200 57TH AVE
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-1710
Practice Address - Country:US
Practice Address - Phone:240-696-3356
Practice Address - Fax:301-883-7890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-30
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty