Provider Demographics
NPI:1285765636
Name:POTOMAC RIDGE- EASTERN SHORE
Entity type:Organization
Organization Name:POTOMAC RIDGE- EASTERN SHORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:P
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, ATR
Authorized Official - Phone:410-221-0288
Mailing Address - Street 1:821 FIELDCREST RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-9423
Mailing Address - Country:US
Mailing Address - Phone:410-221-0288
Mailing Address - Fax:410-221-9588
Practice Address - Street 1:821 FIELDCREST RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-9423
Practice Address - Country:US
Practice Address - Phone:410-221-0288
Practice Address - Fax:410-221-9588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5337322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410520600Medicaid
MD410978300Medicaid