Healthcare Provider Details

I. General information

NPI: 1639487341
Provider Name (Legal Business Name): SIRJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

12 E LAFAYETTE AVE
BALTIMORE MD
21202-2847
US

V. Phone/Fax

Practice location:
  • Phone: 443-977-8406
  • Fax:
Mailing address:
  • Phone: 443-977-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON M LEE-LLACER
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 443-977-8406