Provider Demographics
NPI:1861580847
Name:FAMILY HEALTH CARE CENTER
Entity type:Organization
Organization Name:FAMILY HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PRIBADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-997-9751
Mailing Address - Street 1:10632 LITTLE PATUXENT PKWY
Mailing Address - Street 2:SUITE 111
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6212
Mailing Address - Country:US
Mailing Address - Phone:410-997-9751
Mailing Address - Fax:410-997-9763
Practice Address - Street 1:10632 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 111
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6212
Practice Address - Country:US
Practice Address - Phone:410-997-9751
Practice Address - Fax:410-997-9763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7518Medicare ID - Type Unspecified