Provider Demographics
NPI:1265256531
Name:WESTERN MARYLAND PEDIATRICS
Entity type:Organization
Organization Name:WESTERN MARYLAND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEONATAL, PEDIATRIC NURSE PRACTITI
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:PETRELLA
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:301-707-7270
Mailing Address - Street 1:13210 GROWDENVALE DRIVE NE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502
Mailing Address - Country:US
Mailing Address - Phone:301-707-7270
Mailing Address - Fax:
Practice Address - Street 1:13308 WINCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-707-7270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty