1710998968 NPI number — MEDSTAR SOUTHERN MARYLAND PHYSICIANS, 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 1710998968 NPI number — MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSTAR SOUTHERN MARYLAND PHYSICIANS, 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:
6
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:
1710998968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10403 HOSPITAL DRIVE
Provider Second Line Business Mailing Address:
SUITE G-4
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20735-3134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-856-3019
Provider Business Mailing Address Fax Number:
301-856-9370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7501 SURRATTS RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20735-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-877-7200
Provider Business Practice Location Address Fax Number:
301-877-0100
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAYMOND
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
301-856-3019

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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