Provider Demographics
NPI:1952543191
Name:TYPE 1 INDIVIDUAL PROVIDER
Entity Type:Organization
Organization Name:TYPE 1 INDIVIDUAL PROVIDER
Other - Org Name:TYPE 1 INDIVIDUAL PROVIDER
Other - Org Type:Other Name
Authorized Official - Title/Position:HUMAN RESOURCES DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-439-7191
Mailing Address - Street 1:1620 ELTON RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1740
Mailing Address - Country:US
Mailing Address - Phone:301-439-7191
Mailing Address - Fax:
Practice Address - Street 1:1620 ELTON RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1740
Practice Address - Country:US
Practice Address - Phone:301-439-7191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2381302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization