Basic Information
| Provider Information | |||||||||
| NPI: | 1639206410 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPMC WESTERN MARYLAND CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FBMC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 539 | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215010539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409648343 | ||||||||
| FaxNumber: | 2409648338 | ||||||||
| Practice Location | |||||||||
| Address1: | 10701 NEW GEORGES CREEK RD SW | ||||||||
| Address2: | |||||||||
| City: | FROSTBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215321457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016893229 | ||||||||
| FaxNumber: | 3017231480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | RUBLE | ||||||||
| AuthorizedOfficialFirstName: | AMBER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP. CFO | ||||||||
| AuthorizedOfficialTelephone: | 2409648032 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UPMC WESTERN MARYLAND CORPORATION | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | Y | Laboratories | Physiological Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 62018801 KFA5SA | 01 | MD | CAREFIRST - X-RAY | OTHER | W474SA 61636304 | 01 | MD | CAREFIRST - LAB | OTHER | H857 0001 | 01 | DC | BLUE CHOICE | OTHER |