1083807085 NPI number — PAX RIVER MEDICAL CLINIC, LLC

Table of content: (NPI 1083807085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083807085 NPI number — PAX RIVER MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAX RIVER MEDICAL CLINIC, 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:
1083807085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46940 S SHANGRI LA DR
Provider Second Line Business Mailing Address:
SUITE #19
Provider Business Mailing Address City Name:
LEXINGTON PARK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20653-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-863-8101
Provider Business Mailing Address Fax Number:
301-863-8130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46940 S SHANGRI LA DR
Provider Second Line Business Practice Location Address:
SUITE #19
Provider Business Practice Location Address City Name:
LEXINGTON PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20653-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-863-8101
Provider Business Practice Location Address Fax Number:
301-863-8130
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-863-8101

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  H0055958 , 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: 1437267986 . This is a "INDIVIDUAL NPI #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 011218600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com