Basic Information
| Provider Information | |||||||||
| NPI: | 1598060709 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC | ||||||||
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| OtherOrganizationName: | WALDORF ENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10403 HOSPITAL DR | ||||||||
| Address2: | SUITE G4 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018683019 | ||||||||
| FaxNumber: | 3018569370 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 SAINT PATRICKS DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013968071 | ||||||||
| FaxNumber: | 3013964671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2011 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 3018683019 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.