MEDICARE: CROFTON MEDICAL GROUP, LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1457308090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROFTON MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	1667 CROFTON CTR
Second Line	:	SUITE 5
City	:	CROFTON
State	:	MD
Zip	:	21114-1303
Country	:	US
Telephone Number	:	410-721-2700
Fax Number	:	410-721-8874

Provider Business Practice Location Address
First Line	:	1667 CROFTON CTR
Second Line	:	SUITE 5
City	:	CROFTON
State	:	MD
Zip	:	21114-1303
Country	:	US
Telephone Number	:	410-721-2700
Fax Number	:	410-721-8874

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIRZA M NUSAIREE
Credential	:	M.D.
Telephone Number	:	410-721-2700

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	05/12/2016

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