Healthcare Provider Details

I. General information

NPI: 1801643143
Provider Name (Legal Business Name): PEDIATRIX MEDICAL GROUP OF THE MID-ATLANTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11810 W MARKET PL STE 300
FULTON MD
20759-2703
US

IV. Provider business mailing address

PO BOX 100445
ATLANTA GA
30384-0445
US

V. Phone/Fax

Practice location:
  • Phone: 240-425-4824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier287003703
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: NICHOLAS E. GLASER
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 954-384-0175