Provider Demographics
NPI:1588105316
Name:CITY OF FREDERICK
Entity type:Organization
Organization Name:CITY OF FREDERICK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAMENTA
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-600-3955
Mailing Address - Street 1:100 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5527
Mailing Address - Country:US
Mailing Address - Phone:301-600-1506
Mailing Address - Fax:
Practice Address - Street 1:100 S MARKET ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5527
Practice Address - Country:US
Practice Address - Phone:301-600-1506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD200175600Medicaid
MD21D0885241OtherCLIA