Healthcare Provider Details

I. General information

NPI: 1144986233
Provider Name (Legal Business Name): MEDICAL PRACTICES OF ANTIETAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 THOMAS JOHNSON DR STE 1
FREDERICK MD
21702-4445
US

IV. Provider business mailing address

187 THOMAS JOHNSON DR STE 1
FREDERICK MD
21702-4445
US

V. Phone/Fax

Practice location:
  • Phone: 301-378-9421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA REPAC
Title or Position: CFO
Credential:
Phone: 301-790-9351