Basic Information
| Provider Information | |||||||||
| NPI: | 1477503118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDSTAR PHYSICIAN PARTNERS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDLANTIC HEALTHCARE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 PULASKI PARK DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212201400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105743000 | ||||||||
| FaxNumber: | 4105742261 | ||||||||
| Practice Location | |||||||||
| Address1: | 9600 PULASKI PARK DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212201400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105743000 | ||||||||
| FaxNumber: | 4105742261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | KESSLER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4437258762 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 035476700 | 05 | DC | MEDICAID | DB8990 | 01 | RAILROAD MEDICARE | OTHER | 414263200 | 05 | MD | MEDICAID | 7099 | 01 | CAREFIRST DC | OTHER | B016 | 01 | CAREFIRST DC | OTHER | KF60ME | 01 | CAREFIRST MD | OTHER | 4300 | 01 | CAREFIRST DC | OTHER | 6003 | 01 | CAREFIRST DC | OTHER | 0176 | 01 | CAREFIRST DC | OTHER | 1777 | 01 | CAREFIRST DC | OTHER | J484 | 01 | CAREFIRST DC | OTHER |