Basic Information
| Provider Information | |||||||||
| NPI: | 1124474507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDSTAR HEALTH AT BRANDYWINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDSTAR HEALTH AT BRANDYWINE / PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13950 BRANDYWINE RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206135815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017822220 | ||||||||
| FaxNumber: | 3017822221 | ||||||||
| Practice Location | |||||||||
| Address1: | 13950 BRANDYWINE RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206135815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017822220 | ||||||||
| FaxNumber: | 3017822221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2016 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SYLVESTER | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE AND BILLING | ||||||||
| AuthorizedOfficialTelephone: | 3018774564 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDSTAR AMBULATORY SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.