Provider Demographics
NPI:1659550994
Name:CALVERTHEALTH MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CALVERTHEALTH MEDICAL CENTER, INC.
Other - Org Name:CALVERTHEALTH NON-INVASIVE VASCULAR LAB SERVICES OF CHVH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-535-8239
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4017
Mailing Address - Country:US
Mailing Address - Phone:410-535-8259
Mailing Address - Fax:410-535-8417
Practice Address - Street 1:29449 CHARLOTTE HALL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-3042
Practice Address - Country:US
Practice Address - Phone:410-414-4539
Practice Address - Fax:410-414-4540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALVERT HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-02
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04-001261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD342LMedicare PIN