Provider Demographics
NPI:1093364077
Name:EPIPHANY FAMILY SERVICES MARYLAND LLC
Entity type:Organization
Organization Name:EPIPHANY FAMILY SERVICES MARYLAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-873-7193
Mailing Address - Street 1:3301 BELAIR RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1257
Mailing Address - Country:US
Mailing Address - Phone:443-873-7193
Mailing Address - Fax:410-630-7882
Practice Address - Street 1:3301 BELAIR RD STE 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1257
Practice Address - Country:US
Practice Address - Phone:410-873-7193
Practice Address - Fax:410-630-7882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1104326487Medicaid