Basic Information
Provider Information | |||||||||
NPI: | 1386089183 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONTGOMERY MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10110 MOLECULAR DR | ||||||||
Address2: | SUITE 206 | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208507539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3012792779 | ||||||||
FaxNumber: | 2404030190 | ||||||||
Practice Location | |||||||||
Address1: | 10110 MOLECULAR DR | ||||||||
Address2: | SUITE 206 | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208507539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3012792779 | ||||||||
FaxNumber: | 2404030190 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2013 | ||||||||
LastUpdateDate: | 05/07/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DADGAR | ||||||||
AuthorizedOfficialFirstName: | ANUSHIRAVAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CMO AND FOUNDER | ||||||||
AuthorizedOfficialTelephone: | 3013436505 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H0051280 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.