Healthcare Provider Details

I. General information

NPI: 1336122977
Provider Name (Legal Business Name): PEDIATRIC PARTNERS OF SOUTHERN MARYLAND, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD SUITE 240
CLINTON MD
20735-2549
US

IV. Provider business mailing address

9135 PISCATAWAY RD SUITE 240
CLINTON MD
20735-2549
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-3474
  • Fax: 301-868-4316
Mailing address:
  • Phone: 301-868-3474
  • Fax: 301-868-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KATHY JOHNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-868-3474