Provider Demographics
NPI:1922325398
Name:SOUTHERN MARYLAND COMMUNITY NETWORK, INC.
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND COMMUNITY NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-535-4787
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0998
Mailing Address - Country:US
Mailing Address - Phone:410-535-4787
Mailing Address - Fax:410-535-4965
Practice Address - Street 1:305 PRINCE FREDERICK BLVD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3139
Practice Address - Country:US
Practice Address - Phone:410-535-4787
Practice Address - Fax:410-535-4965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD268873500Medicaid