Healthcare Provider Details

I. General information

NPI: 1003663105
Provider Name (Legal Business Name): PEDIATRIX OF MARYLAND PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

PO BOX 100445
ATLANTA GA
30384-0445
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS E. GLASER
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 954-384-0175