Provider Demographics
NPI:1245740109
Name:75TH STREET INJURY & ILLNESS CENTER LLC
Entity Type:Organization
Organization Name:75TH STREET INJURY & ILLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:410-524-0075
Mailing Address - Street 1:12547 OCEAN GTWY
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9689
Mailing Address - Country:US
Mailing Address - Phone:410-213-0119
Mailing Address - Fax:
Practice Address - Street 1:7408 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-2936
Practice Address - Country:US
Practice Address - Phone:410-524-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty