MEDICARE: LORI E. MADDOX P.A.-C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00097	MS
2	363A00000X	Physician Assistant	15-01067	KS
3	363A00000X	Physician Assistant
4	363A00000X	Physician Assistant	C06664	MD

General Provider Information

NPI Number	:	1215900568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI E. MADDOX P.A.-C.

Provider Business Mailing Address
First Line	:	100 HOSPITAL RD
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-4017
Country	:	US
Telephone Number	:	410-414-4791
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 HOSPITAL RD STE 101
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-4029
Country	:	US
Telephone Number	:	410-535-2500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	06/10/2022

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Directions to “ LORI E. MADDOX P.A.-C.” Practice Location

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