Provider Demographics
NPI:1669086880
Name:CHILDREN'S MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-724-7616
Mailing Address - Street 1:500 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2755
Mailing Address - Country:US
Mailing Address - Phone:301-724-7616
Mailing Address - Fax:301-724-4811
Practice Address - Street 1:500 GREENE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2799
Practice Address - Country:US
Practice Address - Phone:301-724-7616
Practice Address - Fax:301-724-4811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S MEDICAL GROUP, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD910551400Medicaid