Provider Demographics
NPI:1558333138
Name:BROOK LANE HEALTH SERVICES
Entity Type:Organization
Organization Name:BROOK LANE HEALTH SERVICES
Other - Org Name:ADULT PHP
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BISENIEKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0331
Mailing Address - Street 1:13121 BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1435
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13215 BROOK LANE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1435
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3016283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD63503100Medicaid
MD63503100Medicaid
MD986965400Medicaid