Provider Demographics
NPI:1841602877
Name:FOUNDATION MEDICAL CLINIC
Entity Type:Organization
Organization Name:FOUNDATION MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:CHIOMA
Authorized Official - Last Name:NWAOGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-760-4500
Mailing Address - Street 1:420 CRAIN HWY S
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3657
Mailing Address - Country:US
Mailing Address - Phone:410-760-4500
Mailing Address - Fax:410-761-5035
Practice Address - Street 1:808 LANDMARK DR
Practice Address - Street 2:SUITE 116
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4983
Practice Address - Country:US
Practice Address - Phone:410-760-4500
Practice Address - Fax:410-761-5035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-26
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063277261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care