Healthcare Provider Details

I. General information

NPI: 1679858443
Provider Name (Legal Business Name): ADDIS ALEM MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 VAN DUSEN RD
LAUREL MD
20707-9463
US

IV. Provider business mailing address

16501 SHADY GROVE RD 7275
GAITHERSBURG MD
20898-9201
US

V. Phone/Fax

Practice location:
  • Phone: 240-494-6882
  • Fax: 202-403-0508
Mailing address:
  • Phone: 240-494-6882
  • Fax: 202-403-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD0069430
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MARYANN MILLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 240-494-6882