Basic Information
Provider Information | |||||||||
NPI: | 1609227230 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PATIENT FIRST MARYLAND MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATIENT FIRST BELTSVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5000 COX RD | ||||||||
Address2: | STE 100 | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 230609263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8048224588 | ||||||||
FaxNumber: | 8049650987 | ||||||||
Practice Location | |||||||||
Address1: | 10424 BALTIMORE AVE | ||||||||
Address2: |   | ||||||||
City: | BELTSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 207052321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2405425987 | ||||||||
FaxNumber: | 2405425988 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2016 | ||||||||
LastUpdateDate: | 06/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRIDGERS | ||||||||
AuthorizedOfficialFirstName: | MARVIN | ||||||||
AuthorizedOfficialMiddleName: | WARREN | ||||||||
AuthorizedOfficialTitleorPosition: | VP, PHARMACY | ||||||||
AuthorizedOfficialTelephone: | 8048224383 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.