Healthcare Provider Details

I. General information

NPI: 1639131857
Provider Name (Legal Business Name): INFECTIOUS DISEASE ASSO OF SOUTHERN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 PISCATAWAY RD STE 620
CLINTON MD
20735
US

IV. Provider business mailing address

9131 PISCATAWAY RD STE 620
CLINTON MD
20735
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-8044
  • Fax: 301-856-2418
Mailing address:
  • Phone: 301-868-8044
  • Fax: 301-856-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD45851
License Number StateMD

VIII. Authorized Official

Name: PATRICK J HAUGH
Title or Position: PHYSICIAN
Credential: MD
Phone: 301-868-8044