Healthcare Provider Details

I. General information

NPI: 1831415868
Provider Name (Legal Business Name): MARYLAND MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 HOSPITALITY WAY
ABERDEEN MD
21001
US

IV. Provider business mailing address

995 HOSPITALITY WAY
ABERDEEN MD
21001
US

V. Phone/Fax

Practice location:
  • Phone: 410-306-7880
  • Fax: 410-306-7881
Mailing address:
  • Phone: 410-306-7880
  • Fax: 410-306-7881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberM42628
License Number StateMD

VIII. Authorized Official

Name: MR. MARVIN W BRIDGERS III
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 804-822-4383