Healthcare Provider Details

I. General information

NPI: 1992825616
Provider Name (Legal Business Name): MARYLAND PEDIATRIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10807 FALLS RD SUITE 200
LUTHERVILLE MD
21093-4591
US

IV. Provider business mailing address

10807 FALLS RD SUITE 200
LUTHERVILLE MD
21093-4591
US

V. Phone/Fax

Practice location:
  • Phone: 410-321-9393
  • Fax:
Mailing address:
  • Phone: 410-321-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY B CAVALIER
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-427-1600