Healthcare Provider Details

I. General information

NPI: 1699164970
Provider Name (Legal Business Name): MDICS AT FORT WASHINGTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 LIVINGSTON RD
FORT WASHINGTON MD
20744-5151
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 443-949-0814
  • Fax: 443-949-0825
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 State

VIII. Authorized Official

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