1285750059 NPI number — SOUTHERN MARYLAND ORTHOPAEDIC & SPORTS MEDICI NE CENTER PC

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 1285750059 NPI number — SOUTHERN MARYLAND ORTHOPAEDIC & SPORTS MEDICI NE CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MARYLAND ORTHOPAEDIC & SPORTS MEDICI NE CENTER PC
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:
1285750059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23000 MOAKLEY ST
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
LEONARDTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20650-2915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-475-5555
Provider Business Mailing Address Fax Number:
301-475-8535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23000 MOAKLEY ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LEONARDTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20650-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-475-5555
Provider Business Practice Location Address Fax Number:
301-475-8535
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATTINGLY
Authorized Official First Name:
HEIDI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
301-475-5555

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 225731900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2878 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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