Provider Demographics
NPI:1366736779
Name:OLD BRANCH HEALTH CARE
Entity type:Organization
Organization Name:OLD BRANCH HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BALLENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-899-5140
Mailing Address - Street 1:PO BOX 6396
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-6396
Mailing Address - Country:US
Mailing Address - Phone:301-899-5140
Mailing Address - Fax:301-899-5153
Practice Address - Street 1:4333 OLD BRANCH AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-1848
Practice Address - Country:US
Practice Address - Phone:301-899-5140
Practice Address - Fax:301-899-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054991207Q00000X
MDD0046312207R00000X
MDD0019935207R00000X
MDDD36306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty