Basic Information
Provider Information
NPI: 1982753877
EntityType: 2
ReplacementNPI:  
OrganizationName: MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: PEDIATRIC AFTER HOURS, INC.
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 10403 HOSPITAL DRIVE
Address2: SUITE G-04
City: CLINTON
State: MD
PostalCode: 207353134
CountryCode: US
TelephoneNumber: 3018688024
FaxNumber: 3018569370
Practice Location
Address1: 10 SAINT PATRICKS DRIVE
Address2: SUITE 105
City: WALDORF
State: MD
PostalCode: 206034519
CountryCode: US
TelephoneNumber: 3016451414
FaxNumber: 3016454586
Other Information
ProviderEnumerationDate: 01/09/2007
LastUpdateDate: 03/15/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: RAYMOND
AuthorizedOfficialFirstName: JANE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VICE PRESIDENT
AuthorizedOfficialTelephone: 3018563019
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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