Provider Demographics
NPI:1801235015
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:CFO AND SR. VP
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-566-3355
Mailing Address - Street 1:194 THOMAS JOHNSON DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4679
Mailing Address - Country:US
Mailing Address - Phone:240-575-2526
Mailing Address - Fax:240-575-2527
Practice Address - Street 1:75 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4895
Practice Address - Country:US
Practice Address - Phone:301-695-3100
Practice Address - Fax:240-575-2527
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK HEALTH MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-20
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology AssistantGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD336554900Medicaid
MD258583Medicare PIN