Healthcare Provider Details

I. General information

NPI: 1518212786
Provider Name (Legal Business Name): PRIME ALLERGY & ASTHMA CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 SURRATTS RD #202
CLINTON MD
20735-3362
US

IV. Provider business mailing address

PO BOX 26202
ALEXANDRIA VA
22313-6202
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-4616
  • Fax: 301-877-2695
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberD58774
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License NumberD58774
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberD58774
License Number StateMD

VIII. Authorized Official

Name: DR. ROSALYN BAKER
Title or Position: ADULT AND PEDIATRIC ALLERGIST
Credential: M.D., M.H.S.
Phone: 301-877-4620