Healthcare Provider Details

I. General information

NPI: 1083032445
Provider Name (Legal Business Name): BOSTON MEDICAL GROUP- MARYLAND, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 KNOLL DRIVE SUITE 220
COLUMBIA MD
21045
US

IV. Provider business mailing address

5500 KNOLL DRIVE SUITE 220
COLUMBIA MD
21045
US

V. Phone/Fax

Practice location:
  • Phone: 443-542-9241
  • Fax: 443-542-9442
Mailing address:
  • Phone: 443-542-9241
  • Fax: 443-542-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TOM L. LE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 818-808-2828