Provider Demographics
NPI:1477753937
Name:ST. MARY'S HOSPICE PHYSICIAN - MEDICAID
Entity Type:Organization
Organization Name:ST. MARY'S HOSPICE PHYSICIAN - MEDICAID
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:BURBAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-434-7100
Mailing Address - Street 1:22699 WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-0625
Mailing Address - Country:US
Mailing Address - Phone:301-475-6438
Mailing Address - Fax:301-475-6188
Practice Address - Street 1:22699 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-0650
Practice Address - Country:US
Practice Address - Phone:301-475-6438
Practice Address - Fax:301-475-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH1539251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based