Provider Demographics
NPI:1295782910
Name:MERITUS MEDICAL CENTER INC
Entity type:Organization
Organization Name:MERITUS MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-714-4041
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-714-4041
Mailing Address - Fax:301-714-4351
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-714-4041
Practice Address - Fax:301-714-4351
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERITUS MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02116133VN1006X
MDD02101133VN1006X
MDR175330363LF0000X
MDR072839163WD0400X
MDR075263163WD0400X
MDR082255163WD0400X
MDD0042030207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK287Medicare PIN