1922009968 NPI number — SOUTHERN MARYLAND PROFESSIONAL RAD

Table of content: (NPI 1922009968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922009968 NPI number — SOUTHERN MARYLAND PROFESSIONAL RAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MARYLAND PROFESSIONAL RAD
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:
1922009968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7503 SURRATTS ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20735-3358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-870-7001
Provider Business Mailing Address Fax Number:
301-870-6697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7501 SURRATTS ROAD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20735-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-877-4689
Provider Business Practice Location Address Fax Number:
301-868-2298
Provider Enumeration Date:
08/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHIARAMONTE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
301-877-4530

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  137190 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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