1104963990 NPI number — SAM TELLAWI MD PA

Table of content: (NPI 1104963990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104963990 NPI number — SAM TELLAWI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAM TELLAWI MD PA
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:
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:
1104963990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 OLD BRANCH AVE
Provider Second Line Business Mailing Address:
SUITE B-102
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20735-1628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-856-1960
Provider Business Mailing Address Fax Number:
301-856-3206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 RIVERSIDE DR STE A206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801-4704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-912-5640
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORNMAN
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
800-749-5191

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 062048700 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 1104963990 . This is a "MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: A618 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: G02093 . This is a "MEDICARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 632104600 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 8556 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 248N . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DN4447 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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