Provider Demographics
NPI:1619026432
Name:JOPPA HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:JOPPA HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CAC-AD
Authorized Official - Phone:410-259-4985
Mailing Address - Street 1:623 PULASKI HWY # A
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-3914
Mailing Address - Country:US
Mailing Address - Phone:410-538-5809
Mailing Address - Fax:410-538-4249
Practice Address - Street 1:623 PULASKI HWY # A
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-3914
Practice Address - Country:US
Practice Address - Phone:410-538-5809
Practice Address - Fax:410-538-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11026261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD026500400Medicaid
MDMD10077MOtherFDA ID NUMBER