Healthcare Provider Details

I. General information

NPI: 1831719806
Provider Name (Legal Business Name): BLUEROCK PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3429 11TH PL SE
WASHINGTON DC
20032-5903
US

IV. Provider business mailing address

5305 BLACKISTONE RD
BETHESDA MD
20816-1822
US

V. Phone/Fax

Practice location:
  • Phone: 202-796-9775
  • Fax:
Mailing address:
  • Phone: 240-380-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARC BERG
Title or Position: ADMINISTRATOR
Credential:
Phone: 240-380-0402