Healthcare Provider Details

I. General information

NPI: 1487393385
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 ANNAPOLIS RD
ODENTON MD
21113-1012
US

IV. Provider business mailing address

5005 SIGNAL BELL LN STE 200
CLARKSVILLE MD
21029-2608
US

V. Phone/Fax

Practice location:
  • Phone: 410-721-2333
  • Fax:
Mailing address:
  • Phone: 410-730-3399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAJIV DUA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 410-730-3399