Provider Demographics
NPI:1497222103
Name:WALNUT STREET COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:WALNUT STREET COMMUNITY HEALTH CENTER, INC.
Other - Org Name:FAMILY HEALTHCARE OF HAGERSTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-745-3777
Mailing Address - Street 1:201 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-5745
Mailing Address - Country:US
Mailing Address - Phone:301-745-3777
Mailing Address - Fax:301-393-3459
Practice Address - Street 1:221 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6109
Practice Address - Country:US
Practice Address - Phone:301-745-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALNUT STREET COMMUNITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-31
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401662900Medicaid