Healthcare Provider Details

I. General information

NPI: 1376796169
Provider Name (Legal Business Name): GERIATRIC ASSOC BROOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 SLADE SCHOOL RD
SANDY SPRING MD
20860-1313
US

IV. Provider business mailing address

18100 SLADE SCHOOL RD
SANDY SPRING MD
20860-1313
US

V. Phone/Fax

Practice location:
  • Phone: 301-924-2811
  • Fax: 301-924-1200
Mailing address:
  • Phone: 301-924-2811
  • Fax: 301-924-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number062M
License Number StateMD

VIII. Authorized Official

Name: MR. DENNIS KARL HUNTER
Title or Position: VICE PRESIDENT
Credential:
Phone: 301-924-2811