Provider Demographics
NPI:1417036120
Name:MEDICAID SERVICE, LLC
Entity Type:Organization
Organization Name:MEDICAID SERVICE, LLC
Other - Org Name:MEDICAID PERSONAL PROVIDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ELLWOOD
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-495-6330
Mailing Address - Street 1:8555 16TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2802
Mailing Address - Country:US
Mailing Address - Phone:301-495-6330
Mailing Address - Fax:301-495-6332
Practice Address - Street 1:8555 16TH ST STE 105
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2802
Practice Address - Country:US
Practice Address - Phone:301-495-6330
Practice Address - Fax:301-495-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2091251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD474472100Medicaid