1225644701 NPI number — MIRACLE MEDICAL LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225644701 NPI number — MIRACLE MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIRACLE MEDICAL 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:
1225644701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6005 LANDOVER RD STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEVERLY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20785-1145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-687-8690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6005 LANDOVER RD STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEVERLY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20785-1145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-603-0502
Provider Business Practice Location Address Fax Number:
443-790-9236
Provider Enumeration Date:
09/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MAPP
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
ALTAMARIA
Authorized Official Title or Position:
PHYSICINE
Authorized Official Telephone Number:
240-603-0502

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 766166500 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com