Provider Demographics
NPI:1346806502
Name:SPECIALTY PHYSICIANS OF GARRETT
Entity Type:Organization
Organization Name:SPECIALTY PHYSICIANS OF GARRETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO, BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BIRKBY-VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-895-8749
Mailing Address - Street 1:PO BOX 594
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-4594
Mailing Address - Country:US
Mailing Address - Phone:301-895-8750
Mailing Address - Fax:301-895-8751
Practice Address - Street 1:32 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1259
Practice Address - Country:US
Practice Address - Phone:301-895-8750
Practice Address - Fax:301-895-8751
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY PHYSICIANS OF GARRETT COUNTY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541184000Medicaid