1699164970 NPI number — MDICS AT FORT WASHINGTON, 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 1699164970 NPI number — MDICS AT FORT WASHINGTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MDICS AT FORT WASHINGTON, 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:
1699164970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6934 AVIATION BLVD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
GLEN BURNIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21061-2593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-949-0814
Provider Business Mailing Address Fax Number:
443-949-0825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11711 LIVINGSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WASHINGTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20744-5151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-949-0814
Provider Business Practice Location Address Fax Number:
443-949-0825
Provider Enumeration Date:
01/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
443-949-0814

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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