Provider Demographics
NPI:1407045024
Name:SOUTHERN MARYLAND HOSPITAL, INC.
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND HOSPITAL, INC.
Other - Org Name:DEPARTMENT OF PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-877-4541
Mailing Address - Street 1:7503 SURRATTS RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3358
Mailing Address - Country:US
Mailing Address - Phone:301-870-7001
Mailing Address - Fax:301-870-6697
Practice Address - Street 1:7503 SURRATTS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-870-7001
Practice Address - Fax:301-870-6697
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN MARYLAND HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-19
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413384600Medicaid
MD4897, CG1279OtherCAREFIRST NCA & MARYLAND
MD413384600Medicaid