Provider Demographics
NPI:1023091915
Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLERKLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-883-7819
Mailing Address - Street 1:1701 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5329
Mailing Address - Country:US
Mailing Address - Phone:301-883-7819
Mailing Address - Fax:301-883-7890
Practice Address - Street 1:1701 MCCORMICK DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5329
Practice Address - Country:US
Practice Address - Phone:301-883-7819
Practice Address - Fax:301-883-7890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-23
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD70452Medicaid
MD70482Medicaid
MD73008Medicaid
MD70446Medicaid
MD70451Medicaid
MD09841Medicaid
MD44915Medicaid
MD70443Medicaid
MD23484Medicaid
MD45975Medicaid
MD70465Medicaid
MD75012Medicaid
MD00343Medicaid
MD70476Medicaid
MD72015Medicaid
MD70448Medicaid
MD70450Medicaid
MD70480Medicaid