Healthcare Provider Details

I. General information

NPI: 1689472193
Provider Name (Legal Business Name): MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26840 POINT LOOKOUT ROAD
LEONARDTOWN MD
20650-0664
US

IV. Provider business mailing address

24035 THREE NOTCH ROAD
HOLLYWOOD MD
20636-4871
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-5577
  • Fax: 301-475-7419
Mailing address:
  • Phone: 301-373-7900
  • Fax: 301-373-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALAN ADAIR BUSTER
Title or Position: CREDENTIALING
Credential:
Phone: 301-373-7905