South Mountain Family Practice LLC
Organization Active NPI Clinic/Center · Boonsboro, MD
NPI 1487844593 · NPPES record last updated Jun 29, 2011
Key facts
- NPI
- 1487844593
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- License
- D0056826 (MD)
- Legal business name
- SOUTH MOUNTAIN FAMILY PRACTICE LLC
- Practice address
- 9 Saint Paul St
Boonsboro, MD 21713-1334 - Phone
- (301) 432-0623
- Fax
- (301) 432-0624
- NPI assigned
- Jul 26, 2007
- Organization subpart
- No
Authorized official
- Name
- Dr. William F Bodenheimer III, MD
- Title
- Owner
- Phone
- (301) 432-0623
Practitioners 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MD
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041216000151 | MD | Part B Supplier - Clinic/Group Practice | 6406813971 |
Receives reassigned benefits from 1 practitioner Practice locations: Boonsboro, MD |
National Provider Directory
Locations
9 Saint Paul St
Boonsboro, MD 21713
Phone (301) 381-4586
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | D0056826 | MD | Yes |
Addresses
Primary practice location
9 Saint Paul St
Boonsboro, MD 21713-1334
Mailing address
9 Saint Paul St
Boonsboro, MD 21713-1334
Phone (301) 432-0623
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 864001700 | Medicaid | MD |
Other providers in Boonsboro, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 29, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.