Provider Demographics
NPI:1407359532
Name:QUEEN ANNE'S MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:QUEEN ANNE'S MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SPROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-643-6710
Mailing Address - Street 1:2108 REAR DIDONATO DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619
Mailing Address - Country:US
Mailing Address - Phone:410-643-6710
Mailing Address - Fax:410-643-6945
Practice Address - Street 1:2108 REAR DIDONATO DRIVE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619
Practice Address - Country:US
Practice Address - Phone:410-643-6205
Practice Address - Fax:410-643-6945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty