Basic Information
| Provider Information | |||||||||
| NPI: | 1972770519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN MARYLAND HOSPITAL ,INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEPARTMENT OF OBSTETRICS & GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7503 SURRATTS RD | ||||||||
| Address2: | SUITE G125 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Practice Location | |||||||||
| Address1: | 7503 SURRATTS RD | ||||||||
| Address2: | SUITE G125 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3018774541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN MARYLAND HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 9158, LR78SO | 01 | MD | CAREFIRST NCA & MARYLAND GROUP NUMBERS | OTHER | 410566400 | 05 | MD | MEDICAID |