Provider Demographics
NPI:1578821153
Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-883-7822
Mailing Address - Street 1:1701 MCCORMICK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5329
Mailing Address - Country:US
Mailing Address - Phone:301-883-7822
Mailing Address - Fax:301-883-7890
Practice Address - Street 1:3003 HOSPITAL DRIVE - GROUND FLOOR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785
Practice Address - Country:US
Practice Address - Phone:301-583-5920
Practice Address - Fax:301-583-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD750121800OtherMA PROVIDER #