1639019573 NPI number — MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC

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 1639019573 NPI number — MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND 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:
1639019573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24035 THREE NOTCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20636-4871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-373-7900
Provider Business Mailing Address Fax Number:
301-373-6900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3261 OLD WASHINGTON RD STE 1012
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20602-3228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-843-9060
Provider Business Practice Location Address Fax Number:
301-645-3092
Provider Enumeration Date:
03/31/2026

Additional Information

Authorized Official

Authorized Official Last Name:
BUSTER
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
ADAIR
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
301-373-7905

Provider Taxonomy Codes

  • 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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