Provider Demographics
NPI:1336647577
Name:JASON A TATE
Entity Type:Organization
Organization Name:JASON A TATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-756-9110
Mailing Address - Street 1:PO BOX 973
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21158-0973
Mailing Address - Country:US
Mailing Address - Phone:410-848-5785
Mailing Address - Fax:410-848-5629
Practice Address - Street 1:76 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:TANEYTOWN
Practice Address - State:MD
Practice Address - Zip Code:21787-2135
Practice Address - Country:US
Practice Address - Phone:410-756-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1906011Medicaid