Provider Demographics
NPI:1659702215
Name:CHARLES COUNTY DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:CHARLES COUNTY DEPARTMENT OF HEALTH
Other - Org Name:WESTERN COUNTY FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINSTRATION
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-6906
Mailing Address - Street 1:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-1050
Mailing Address - Country:US
Mailing Address - Phone:301-609-6906
Mailing Address - Fax:
Practice Address - Street 1:4375 PORT TOBACCO RD
Practice Address - Street 2:
Practice Address - City:NANJEMOY
Practice Address - State:MD
Practice Address - Zip Code:20662-3345
Practice Address - Country:US
Practice Address - Phone:301-609-6906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420862500Medicaid
MDVA04Medicare PIN
MD070061400Medicaid