1184098634 NPI number — MMLC URGENT CARE WOUND CARE SERVICES LLC

Table of content: (NPI 1184098634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184098634 NPI number — MMLC URGENT CARE WOUND CARE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMLC URGENT CARE WOUND CARE SERVICES 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:
1184098634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 SPRING ST
Provider Second Line Business Mailing Address:
SUITE 122
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20910-3616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-585-1833
Provider Business Mailing Address Fax Number:
301-448-1202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 SPRING ST
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20910-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-585-1833
Provider Business Practice Location Address Fax Number:
301-448-1202
Provider Enumeration Date:
11/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MAJOR
Authorized Official First Name:
MARK
Authorized Official Middle Name:
AMMAAN
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
301-585-1833

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D0064592 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 032809000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7578010001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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