Healthcare Provider Details

I. General information

NPI: 1003613043
Provider Name (Legal Business Name): MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 PISCATAWAY RD STE 610
CLINTON MD
20735-2568
US

IV. Provider business mailing address

24035 THREE NOTCH RD
HOLLYWOOD MD
20636-4871
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-2106
  • Fax: 301-868-6757
Mailing address:
  • Phone: 301-373-7900
  • Fax: 301-373-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ALAN ADAIR BUSTER
Title or Position: CREDENTIALING
Credential:
Phone: 301-373-7905