Healthcare Provider Details

I. General information

NPI: 1508151770
Provider Name (Legal Business Name): MDICS AT SOUTHERN MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

6934 AVIATION BLVD SUITE B
GLEN BURNIE MD
21061-2593
US

V. Phone/Fax

Practice location:
  • Phone: 301-856-0911
  • Fax: 301-868-8000
Mailing address:
  • Phone: 443-949-0814
  • Fax: 443-949-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. DOUGLAS S MITCHELL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 443-949-0814