Healthcare Provider Details

I. General information

NPI: 1083411979
Provider Name (Legal Business Name): FREDERICK PRIMARY CARE ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

9093 RIDGEFIELD DR STE 104
FREDERICK MD
21701-6711
US

IV. Provider business mailing address

610 SOLAREX CT
FREDERICK MD
21703-8624
US

V. Phone/Fax

Practice location:
  • Phone: 240-913-5950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SCOTT R LILLY
Title or Position: CEO
Credential:
Phone: 301-663-6162