Healthcare Provider Details

I. General information

NPI: 1942875026
Provider Name (Legal Business Name): OWENSVILLE PRIMARY CARE,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5408 SOUTHERN MARYLAND BLVD UNIT 7
LOTHIAN MD
20711-2602
US

IV. Provider business mailing address

134 OWENSVILLE RD
WEST RIVER MD
20778-9702
US

V. Phone/Fax

Practice location:
  • Phone: 410-867-4700
  • Fax: 410-867-4934
Mailing address:
  • Phone: 410-867-4700
  • Fax: 410-867-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA VARGA
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 410-867-4700