Healthcare Provider Details

I. General information

NPI: 1104963990
Provider Name (Legal Business Name): SAM TELLAWI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 RIVERSIDE DR STE A206
SALISBURY MD
21801-4704
US

IV. Provider business mailing address

7700 OLD BRANCH AVE SUITE B-102
CLINTON MD
20735-1628
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-5640
  • Fax:
Mailing address:
  • Phone: 301-856-1960
  • Fax: 301-856-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA CORNMAN
Title or Position: MANAGER
Credential:
Phone: 800-749-5191