Provider Demographics
NPI:1609844018
Name:WALDORF INTEGRATED HEALTHCARE, LLC
Entity type:Organization
Organization Name:WALDORF INTEGRATED HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:CMM
Authorized Official - Phone:301-645-9551
Mailing Address - Street 1:PO BOX 1565
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20604-1565
Mailing Address - Country:US
Mailing Address - Phone:301-645-9551
Mailing Address - Fax:301-645-0039
Practice Address - Street 1:29015 THREE NOTCH RD
Practice Address - Street 2:SUITE 1-A
Practice Address - City:MECHANICSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20659-3228
Practice Address - Country:US
Practice Address - Phone:301-290-5285
Practice Address - Fax:301-290-5287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216NMedicare PIN