Healthcare Provider Details

I. General information

NPI: 1316296791
Provider Name (Legal Business Name): MEDSTAR SOUTHERN MARYLAND PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-8000
  • Fax:
Mailing address:
  • Phone: 301-868-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORA J. KUCHKA-CRAIG
Title or Position: CORPORATE VICE PRESIDENT
Credential:
Phone: 410-772-6827