Healthcare Provider Details

I. General information

NPI: 1093584930
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15646 OLD COLUMBIA PIKE
BURTONSVILLE MD
20866-1630
US

IV. Provider business mailing address

6230 OLD DOBBIN LN
COLUMBIA MD
21045-5803
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-3399
  • Fax: 443-478-4747
Mailing address:
  • Phone: 410-730-3399
  • Fax: 443-478-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJIV DUA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 410-730-3399