Basic Information
| Provider Information | |||||||||
| NPI: | 1053346759 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERITUS MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOHN MARSH CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11116 MEDICAL CAMPUS RD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017908000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11110 MEDICAL CAMPUS RD | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217426700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016654650 | ||||||||
| FaxNumber: | 3017979480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3017908102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERITUS MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 21-012 | MD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | NW5 | 01 | MD | BLUECROSS-FEP/GHMSI | OTHER | 263416 | 01 | MD | MAMSI-CHEMO | OTHER | 61284701 | 01 | MD | BLUECROSS-MARYLAND | OTHER | 363416 | 01 | MD | MAMSI-RADIATION | OTHER |