Healthcare Provider Details

I. General information

NPI: 1457592685
Provider Name (Legal Business Name): MINIMALLY INVASIVE VASCULAR CENTER OF MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 02/08/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8730 CHERRY LANE SUITE 10
LAUREL MD
20707
US

IV. Provider business mailing address

8730 CHERRY LN STE 10
LAUREL MD
20707-6212
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-1590
  • Fax: 240-334-4781
Mailing address:
  • Phone: 301-497-1590
  • Fax: 240-334-4781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberH0065639
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD0034245
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberH0065639
License Number StateMD

VIII. Authorized Official

Name: WENDY L MUHAMMAD
Title or Position: PRESIDENT
Credential:
Phone: 301-497-1590