Healthcare Provider Details

I. General information

NPI: 1922009968
Provider Name (Legal Business Name): SOUTHERN MARYLAND PROFESSIONAL RAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 SURRATTS ROAD SUITE 104
CLINTON MD
20735-3362
US

IV. Provider business mailing address

7503 SURRATTS ROAD
CLINTON MD
20735-3358
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-4689
  • Fax: 301-868-2298
Mailing address:
  • Phone: 301-870-7001
  • Fax: 301-870-6697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number137190
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL J. CHIARAMONTE
Title or Position: PRESIDENT
Credential: PRESIDENT
Phone: 301-877-4530