Provider Demographics
NPI:1376785998
Name:PENINSULA REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:PENINSULA REGIONAL MEDICAL CENTER
Other - Org Name:PENINSULA REGIONAL OCCUPATIONAL HEALTH/URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-543-7531
Mailing Address - Street 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7252
Mailing Address - Fax:410-912-6386
Practice Address - Street 1:1655 WOODBROOKE DR STE 104
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8502
Practice Address - Country:US
Practice Address - Phone:410-548-2700
Practice Address - Fax:410-548-2608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK230Medicare PIN