Provider Demographics
NPI:1154345981
Name:STATE OF MARYLAND
Entity type:Organization
Organization Name:STATE OF MARYLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:POLSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:410-535-5400
Mailing Address - Street 1:PO BOX 980
Mailing Address - Street 2:975 SOLOMONS ISLAND RD N
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0980
Mailing Address - Country:US
Mailing Address - Phone:410-535-5400
Mailing Address - Fax:410-535-5285
Practice Address - Street 1:975 SOLOMONS ISLAND RD N
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-0980
Practice Address - Country:US
Practice Address - Phone:410-535-5400
Practice Address - Fax:410-535-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD50213251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002FMedicare PIN