Provider Demographics
NPI:1932388493
Name:SOUTH MOUNTAIN COMMUNITY HEALTH LLC
Entity Type:Organization
Organization Name:SOUTH MOUNTAIN COMMUNITY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:GALLOWAY
Authorized Official - Last Name:ELIZALDE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-432-6897
Mailing Address - Street 1:9 SAINT PAUL ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BOONSBORO
Mailing Address - State:MD
Mailing Address - Zip Code:21713-1334
Mailing Address - Country:US
Mailing Address - Phone:301-432-6897
Mailing Address - Fax:301-432-6298
Practice Address - Street 1:9 SAINT PAUL ST STE 3
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713
Practice Address - Country:US
Practice Address - Phone:301-432-6897
Practice Address - Fax:301-432-6298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR100650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD544300800Medicaid
MD544300800Medicaid