Basic Information
| Provider Information | |||||||||
| NPI: | 1538165527 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREDERICK HEALTH HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FREDERICK HEALTH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 277045 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303847045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405663300 | ||||||||
| FaxNumber: | 2405663892 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W 7TH ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405663300 | ||||||||
| FaxNumber: | 2405663892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAHAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 2405663355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FREDERICK HEALTH HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QX0203X | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation | 282N00000X | 10001 | MD | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4020106 | 01 | CIGNA | OTHER | 5000066 | 01 | UNITED | OTHER | 6310365 | 01 | AETNA PIN | OTHER | 0249 | 01 | CAREFIRST MARYLAND | OTHER | 211417 | 01 | UNITED MAMSI | OTHER | 60286 | 01 | AETNA PVN | OTHER | GN-4 | 01 | CAREFIRST BCBS GHMSI | OTHER | 482770 | 01 | NCPPO | OTHER | 000235600 | 05 | MD | MEDICAID |