Provider Demographics
NPI:1285006288
Name:JARRETT CORPORATION
Entity Type:Organization
Organization Name:JARRETT CORPORATION
Other - Org Name:FREDERICK FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MONYA-TAMBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-370-5348
Mailing Address - Street 1:45 WAVERLEY DR
Mailing Address - Street 2:SUITE O
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4854
Mailing Address - Country:US
Mailing Address - Phone:301-624-5999
Mailing Address - Fax:301-624-5997
Practice Address - Street 1:45 WAVERLEY DR
Practice Address - Street 2:SUITE O
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4854
Practice Address - Country:US
Practice Address - Phone:301-624-5999
Practice Address - Fax:301-624-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076463261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1386829679Medicaid