Healthcare Provider Details

I. General information

NPI: 1326596974
Provider Name (Legal Business Name): MEDBALANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD SUITE N270
BETHESDA MD
20816-2508
US

IV. Provider business mailing address

4701 SANGAMORE RD SUITE N270
BETHESDA MD
20816-2508
US

V. Phone/Fax

Practice location:
  • Phone: 240-507-5110
  • Fax: 844-682-8102
Mailing address:
  • Phone: 240-507-5110
  • Fax: 844-682-8102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD59980
License Number StateMD

VIII. Authorized Official

Name: SANDRA DELISTATHIS
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 240-507-5110