Basic Information
| Provider Information | |||||||||
| NPI: | 1528502036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERDYNAMICS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 FORBES BLVD | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207064807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013064590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 FORBES BOULEVARD | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207064807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013064590 | ||||||||
| FaxNumber: | 3018800054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2016 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRANCH | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3013064590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 01660 | MD | N | Agencies | Case Management | 251S00000X | 01160 | MD | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 535443 | 01 | MD | PTAN | OTHER |