Provider Demographics
NPI:1962423228
Name:THE GYNECOLOGY CENTER, LLC
Entity type:Organization
Organization Name:THE GYNECOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTAMARINO-BEHNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-759-3924
Mailing Address - Street 1:925 BISHOP WALSH ROAD
Mailing Address - Street 2:STE # 8
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502
Mailing Address - Country:US
Mailing Address - Phone:301-759-3924
Mailing Address - Fax:301-759-4632
Practice Address - Street 1:925 BISHOP WALSH ROAD
Practice Address - Street 2:STE # 8
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-759-3924
Practice Address - Fax:301-759-4632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1363261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401097300Medicaid
MD154ZMedicare PIN