1770565731 NPI number — GASTROINTESTINAL ASSOCIATES OF MARYLAND PA

Table of content: (NPI 1770565731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770565731 NPI number — GASTROINTESTINAL ASSOCIATES OF MARYLAND PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROINTESTINAL ASSOCIATES OF MARYLAND PA
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:
1770565731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12070 OLD LINE CTR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
WALDORF
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20602-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-645-8035
Provider Business Mailing Address Fax Number:
301-645-5229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6710 OXON HILL RD STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXON HILL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20745-1117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-292-2300
Provider Business Practice Location Address Fax Number:
301-292-8025
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
LEGINA
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
301-645-8035

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 035197200 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155700900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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