Healthcare Provider Details

I. General information

NPI: 1023424363
Provider Name (Legal Business Name): GWMFA-MEDICAL FACULTY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9715 MEDICAL CENTER DR SUITE 230
ROCKVILLE MD
20850-3320
US

IV. Provider business mailing address

9715 MEDICAL CENTER DR SUITE 230
ROCKVILLE MD
20850-3320
US

V. Phone/Fax

Practice location:
  • Phone: 240-994-8650
  • Fax:
Mailing address:
  • Phone: 240-994-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberPA031061
License Number StateDC

VIII. Authorized Official

Name: THOMAS KOROTKA
Title or Position: PA-C
Credential:
Phone: 240-994-8650