Healthcare Provider Details

I. General information

NPI: 1699572396
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10981 JOHNS HOPKINS RD
LAUREL MD
20723-6002
US

IV. Provider business mailing address

6230 OLD DOBBIN LN STE 230
COLUMBIA MD
21045-5884
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-3399
  • Fax: 443-478-4737
Mailing address:
  • Phone: 410-730-3399
  • Fax: 443-478-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RIA YOUNG
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 410-730-3399