Basic Information
| Provider Information | |||||||||
| NPI: | 1346694718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 610 DUTCHMANS LANE OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PINES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 DUTCHMANS LN | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216013346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 610 DUTCHMANS LN | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216013346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108224000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 09/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 20002 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 20002 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 552405900 | 05 | MD | MEDICAID |