Provider Demographics
NPI:1952912487
Name:ERICKSON HEALTH MEDICAL GROUP OF MARYLAND, PC
Entity Type:Organization
Organization Name:ERICKSON HEALTH MEDICAL GROUP OF MARYLAND, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:ETHEL
Authorized Official - Last Name:RACHUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-402-2258
Mailing Address - Street 1:PO BOX 783712
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3712
Mailing Address - Country:US
Mailing Address - Phone:800-360-3851
Mailing Address - Fax:410-402-2265
Practice Address - Street 1:3110 GRACEFIELD RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1820
Practice Address - Country:US
Practice Address - Phone:301-572-8340
Practice Address - Fax:301-572-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty