Provider Demographics
NPI:1619411121
Name:FREDERICK PSYCHIATRIC MEDICINE
Entity Type:Organization
Organization Name:FREDERICK PSYCHIATRIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-606-7785
Mailing Address - Street 1:10001 PEBBLE BEACH TER
Mailing Address - Street 2:
Mailing Address - City:IJAMSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21754-9147
Mailing Address - Country:US
Mailing Address - Phone:301-606-7785
Mailing Address - Fax:240-310-1927
Practice Address - Street 1:10001 PEBBLE BEACH TER
Practice Address - Street 2:
Practice Address - City:IJAMSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21754-9147
Practice Address - Country:US
Practice Address - Phone:301-606-7785
Practice Address - Fax:240-310-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO448572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD60054OtherAETNA
MDMDMCDMedicaid
00823OtherVALUE OPTIONS
MDSKMDOMedicaid
MDSB580OtherBLUE CROSS/BLUE SHIELD
MDD0044857OtherMEDICAL LICENSE
MDSX173OtherBEACON HEALTH
MDSKMDOMedicaid