Provider Demographics
NPI:1427590488
Name:ALLEGANY COLLEGE OF MARYLAND
Entity Type:Organization
Organization Name:ALLEGANY COLLEGE OF MARYLAND
Other - Org Name:NURSE MANAGED WELLNESS CLINIC LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KEPHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-784-5670
Mailing Address - Street 1:12401 WILLOWBROOK RD
Mailing Address - Street 2:ALLIED HEALTH BUILDING, ROOM 115
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2559
Mailing Address - Country:US
Mailing Address - Phone:301-784-5670
Mailing Address - Fax:301-784-5093
Practice Address - Street 1:12401 WILLOWBROOK RD
Practice Address - Street 2:ALLIED HEALTH BUILDING, ROOM 115
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2559
Practice Address - Country:US
Practice Address - Phone:301-784-5670
Practice Address - Fax:301-784-5093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLEGANY COLLEGE OF MARYLAND NURSE MANAGED WELLNESS CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-08
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR081546363LF0000X
MDR095433363LF0000X
MD21D2093034291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1659709558OtherNPI
MD1013463561OtherNPI
MD1548410921OtherNPI