Provider Demographics
NPI:1902232168
Name:MEDICAL HOME DEVELOPMENT GROUP
Entity Type:Organization
Organization Name:MEDICAL HOME DEVELOPMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHETSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:843-412-5548
Mailing Address - Street 1:4975 LACROSS RD
Mailing Address - Street 2:SUITE 151
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6523
Mailing Address - Country:US
Mailing Address - Phone:843-412-5548
Mailing Address - Fax:866-643-9237
Practice Address - Street 1:2112 F ST NW STE 504
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2761
Practice Address - Country:US
Practice Address - Phone:202-684-2784
Practice Address - Fax:866-643-9237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC086030300Medicaid