Basic Information
| Provider Information | |||||||||
| NPI: | 1730571118 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24035 THREE NOTCH RD | ||||||||
| Address2: | PO BOX 640 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206364871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013737900 | ||||||||
| FaxNumber: | 3013736900 | ||||||||
| Practice Location | |||||||||
| Address1: | 24035 THREE NOTCH RD | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206364871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013737900 | ||||||||
| FaxNumber: | 3013736900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4107726595 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | A1234 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 80071330 | 05 | MD | MEDICAID |