1003613043 NPI number — MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC

Table of content: (NPI 1003613043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003613043 NPI number — MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003613043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24035 THREE NOTCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20636-4871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-373-7900
Provider Business Mailing Address Fax Number:
301-373-6900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9131 PISCATAWAY RD STE 610
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20735-2568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-868-2106
Provider Business Practice Location Address Fax Number:
301-868-6757
Provider Enumeration Date:
02/27/2025

Additional Information

Authorized Official

Authorized Official Last Name:
BUSTER
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
ADAIR
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
301-373-7905

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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