Basic Information
| Provider Information | |||||||||
| NPI: | 1831386630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN MARYLAND PRIMARY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1558 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016389670 | ||||||||
| FaxNumber: | 3016387558 | ||||||||
| Practice Location | |||||||||
| Address1: | 3460 OLD WASHINGTON RD | ||||||||
| Address2: | SUITE 203A | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016389670 | ||||||||
| FaxNumber: | 3016387558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | NIRAN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3016389670 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D78727 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 431203100 | 05 | MD | MEDICAID | F247 | 01 | DC | BLUE CROSS | OTHER |