1063692291 NPI number — PATUXENT RHEUMATOLOGY ASSOCIATES,LLC

Table of content: (NPI 1063692291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063692291 NPI number — PATUXENT RHEUMATOLOGY ASSOCIATES,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATUXENT RHEUMATOLOGY ASSOCIATES,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:
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:
1063692291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 424
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-0424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-414-3437
Provider Business Mailing Address Fax Number:
410-414-3451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 N. PRINCE FREDERICK BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-3151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-414-3437
Provider Business Practice Location Address Fax Number:
410-414-3451
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GEORGE
Authorized Official First Name:
ASHA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
410-414-3437

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  D0059442 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2121894 . This is a "FELRA & GEHA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 408633300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7253531 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 395A-PA . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: J527 . This is a "BLUE CHOICE AND FED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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