Davidsonville Pediatrics

Primary specialty

Non-Pharmacy Dispensing SiteTaxonomy code 332900000X

License

D0013889 Issued in MD

Legal business name

DAVIDSONVILLE PEDIATRICS

Practice address

2772 Rutland Rd
Davidsonville, MD 21035-1228

Phone

(410) 269-7828

Fax

(410) 269-0510

NPI assigned

Oct 24, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Direndia Shackelford

Title

Managed Care Specialist

Phone

(800) 654-0889

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• DAVIDSONVILLE PEDIATRICS Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

The Pediatric Group3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• The Pediatric Group LLP

  • Pediatrics Physician
  • Severna Park, MD
  • NPI 1235942079
  NPD tax ID
• The Pediatric Group, LLP

  • Pediatrics Physician
  • Davidsonville, MD
  • NPI 1598779886
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1679657209",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2772 RUTLAND RD",
            "city": "DAVIDSONVILLE",
            "state": "MD",
            "postal_code": "210351228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2772 RUTLAND RD",
            "city": "DAVIDSONVILLE",
            "state": "MD",
            "postal_code": "210351228",
            "telephone_number": "410-269-7828",
            "fax_number": "410-269-0510"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVIDSONVILLE PEDIATRICS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "SHACKELFORD",
        "authorized_official_first_name": "DIRENDIA",
        "authorized_official_title_or_position": "MANAGED CARE SPECIALIST",
        "authorized_official_telephone_number": "800-654-0889"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "MD",
            "license": "D0013889",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "2124410",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "DAVIDSONVILLE PEDIATRICS",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Lee Collins, LCPC
• Lauren Corrigan
• Creative Enterprises, Inc.
• Rebecca M Damore, CPNP
• Davidsonville Dental Group LLC
• Loren Dlugos
• Kim Alison Edwards, RN
• Pamela P Fahr, MN, C-FNP
• Carol Macneal Gillies, PA-C
• Robert G. Graw Jr., M.D.

• All providers in Davidsonville, MD
• Non-Pharmacy Dispensing Site in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.