Provider Demographics
NPI:1629296801
Name:MERITUS MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MERITUS MEDICAL CENTER INC
Other - Org Name:MERITUS PULMONARY FUNCTION LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FIANCIAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-797-2000
Mailing Address - Street 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:301-797-2000
Mailing Address - Fax:
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-797-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERITUS MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21-012225B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH403Medicare ID - Type UnspecifiedMEDIARE PART B