Provider Demographics
NPI:1558718668
Name:CALVERTHEALTH MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CALVERTHEALTH MEDICAL CENTER, INC.
Other - Org Name:CALVERTHEALTH OUTPATIENT REHABILITATION PRINCE FREDERICK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-535-8239
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:ATT: CONTRACT & CREDENTIALING
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4017
Mailing Address - Country:US
Mailing Address - Phone:410-414-4791
Mailing Address - Fax:410-414-4558
Practice Address - Street 1:130 HOSPITAL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4015
Practice Address - Country:US
Practice Address - Phone:410-535-8180
Practice Address - Fax:410-535-8325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALVERT HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-18
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD728804202Medicaid