Healthcare Provider Details

I. General information

NPI: 1184481459
Provider Name (Legal Business Name): MEDICAL PRACTICES OF ANTIETAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

17301 VALLEY MALL RD STE 125
HAGERSTOWN MD
21740-6966
US

IV. Provider business mailing address

11116 MEDICAL CAMPUS RD
HAGERSTOWN MD
21742-6710
US

V. Phone/Fax

Practice location:
  • Phone: 301-790-9237
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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