Basic Information
| Provider Information | |||||||||
| NPI: | 1427093343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC | ||||||||
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| OtherOrganizationName: | UPPER MARLBORO FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10403 HOSPITAL DRIVE | ||||||||
| Address2: | SUITE G-4 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018563019 | ||||||||
| FaxNumber: | 3018569370 | ||||||||
| Practice Location | |||||||||
| Address1: | 6409 SOUTH CRAIN HIGHWAY | ||||||||
| Address2: | ROUTE 301 | ||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019528614 | ||||||||
| FaxNumber: | 3019529030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3018563019 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.