Healthcare Provider Details

I. General information

NPI: 1497790398
Provider Name (Legal Business Name): MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 HOSPITAL DRIVE SUITE G-4
CLINTON MD
20735-3134
US

IV. Provider business mailing address

10403 HOSPITAL DRIVE SUITE G-04
CLINTON MD
20735-3134
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-0891
  • Fax: 301-856-0536
Mailing address:
  • Phone: 301-856-3019
  • Fax: 301-856-9370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANE RAYMOND
Title or Position: VICE PRESIDENT
Credential:
Phone: 301-856-3019