Provider Demographics
NPI:1508163320
Name:ST. MARY'S HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:ST. MARY'S HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BRIDGETT
Authorized Official - Suffix:I
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-475-4330
Mailing Address - Street 1:21580 PEABODY ST
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2962
Mailing Address - Country:US
Mailing Address - Phone:301-475-4330
Mailing Address - Fax:301-475-4383
Practice Address - Street 1:21580 PEABODY ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2962
Practice Address - Country:US
Practice Address - Phone:301-475-4330
Practice Address - Fax:301-475-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR096847261QA0005X, 261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========Medicaid