Provider Demographics
NPI:1649419235
Name:QUILLIN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:QUILLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11544 QUILLIN WAY
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2567
Mailing Address - Country:US
Mailing Address - Phone:410-629-1126
Mailing Address - Fax:
Practice Address - Street 1:11827 OCEAN GATEWAY
Practice Address - Street 2:WORCESTER COUNTY HEALTH DEPARTMENT - WACS CENTER
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842
Practice Address - Country:US
Practice Address - Phone:410-213-0202
Practice Address - Fax:410-213-1408
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0740101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD705371101Medicaid
MDS013Medicare UPIN