1477351013 NPI number — MEDICAL PRACTICES OF ANTIETAM LLC

Table of content: (NPI 1477351013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477351013 NPI number — MEDICAL PRACTICES OF ANTIETAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL PRACTICES OF ANTIETAM 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:
1477351013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11116 MEDICAL CAMPUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-6710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4991 NEW DESIGN RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21703-7342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-790-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2025

Additional Information

Authorized Official

Authorized Official Last Name:
REPAC
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
301-790-9351

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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