Provider Demographics
NPI:1265920615
Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-883-7822
Mailing Address - Street 1:1701 MCCORMICK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5329
Mailing Address - Country:US
Mailing Address - Phone:301-883-7822
Mailing Address - Fax:301-883-7890
Practice Address - Street 1:6501 COLUMBIA PARK RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-3970
Practice Address - Country:US
Practice Address - Phone:240-573-7255
Practice Address - Fax:301-883-7890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT- SBW: FAIRMONT HEIGHTS H.S.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-01
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local