MEDICARE: OLNEY 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	D43430	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720019011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLNEY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 157
Second Line	:
City	:	ASHTON
State	:	MD
Zip	:	20861-0157
Country	:	US
Telephone Number	:	301-570-9700
Fax Number	:	301-260-2838

Provider Business Practice Location Address
First Line	:	3411 OLANDWOOD CT
Second Line	:	SUITE 105
City	:	OLNEY
State	:	MD
Zip	:	20832-1488
Country	:	US
Telephone Number	:	301-774-5260
Fax Number	:	301-774-1336

Authorized Official
Title or Position	:	OWNER
Name	:	GAURANG THAKER
Credential	:	MD
Telephone Number	:	301-774-5260

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	06/30/2010

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Directions to “OLNEY MEDICAL GROUP, LLC ” Practice Location

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