Provider Demographics
NPI:1780092916
Name:FREDERICK HEALTH MEDICAL GROUP LLC
Entity type:Organization
Organization Name:FREDERICK HEALTH MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VP AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-566-3355
Mailing Address - Street 1:3430 WORTHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7017
Mailing Address - Country:US
Mailing Address - Phone:301-874-2163
Mailing Address - Fax:
Practice Address - Street 1:3430 WORTHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7017
Practice Address - Country:US
Practice Address - Phone:301-874-2163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK HEALTH MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-31
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care