Provider Demographics
NPI:1922546142
Name:MID-ATLANTIC OF FAIRFIELD, LLC
Entity Type:Organization
Organization Name:MID-ATLANTIC OF FAIRFIELD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF AR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-923-2415
Mailing Address - Street 1:1454 FAIRFIELD LOOP RD
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-2006
Mailing Address - Country:US
Mailing Address - Phone:410-923-6820
Mailing Address - Fax:410-923-2416
Practice Address - Street 1:1454 FAIRFIELD LOOP RD
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-2006
Practice Address - Country:US
Practice Address - Phone:410-923-6820
Practice Address - Fax:410-923-2416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02008314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD556234100Medicaid