Basic Information
| Provider Information | |||||||||
| NPI: | 1760406110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL & SURGICAL CLINICS OF SOUTHERN MARYLAND INC | ||||||||
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| OtherOrganizationName: | SMHC OBGYN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10403 HOSPITAL DRIVE | ||||||||
| Address2: | SUITE G-04 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018563019 | ||||||||
| FaxNumber: | 3018569370 | ||||||||
| Practice Location | |||||||||
| Address1: | 7700 OLD BRANCH AVE | ||||||||
| Address2: | SUITE 104A | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018688888 | ||||||||
| FaxNumber: | 3018680409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3018563019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL & SURGICAL CLINICS OF SOUTHERN MARYLAND INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 222101200 | 05 | MD | MEDICAID | B776 | 01 | CAREFIRST NCA/MD | OTHER | KR10ME | 01 | CAREFIRST NCA/MD | OTHER |