Provider Demographics
NPI:1457956948
Name:AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:AMBUSH PEDIATRICS AND FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:EBONY
Authorized Official - Last Name:AMBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:410-707-5947
Mailing Address - Street 1:11610 CLARKSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6142
Mailing Address - Country:US
Mailing Address - Phone:410-609-6677
Mailing Address - Fax:410-609-6672
Practice Address - Street 1:4367 HOLLINS FERRY RD STE 1C
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3400
Practice Address - Country:US
Practice Address - Phone:410-609-6677
Practice Address - Fax:410-609-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD080454100Medicaid