Provider Demographics
NPI:1851799936
Name:QUEEN ANNE'S COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:QUEEN ANNE'S COUNTY HEALTH DEPARTMENT
Other - Org Name:QUEEN ANNE'S COUNTY ALCOHOL AND DRUG ABUSE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCADC
Authorized Official - Phone:410-758-1306
Mailing Address - Street 1:206 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-1049
Mailing Address - Country:US
Mailing Address - Phone:410-758-1306
Mailing Address - Fax:410-758-2133
Practice Address - Street 1:205 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-1022
Practice Address - Country:US
Practice Address - Phone:410-758-1306
Practice Address - Fax:410-758-2133
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEEN ANNE'S COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-05
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD750325261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD019364OtherVALUE OPTIONS
MDH93OtherBC&BS
MDH93OtherCAREFIRST BLUE CHOICE
MD423239900Medicaid
MDH93OtherCAREFRSIT BCBS OF MD
MDH93OtherCAREFRSIT BCBS OF MD