Healthcare Provider Details

I. General information

NPI: 1427444108
Provider Name (Legal Business Name): WASHINGTON MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 PROSPERITY DR SUITE # 320
SILVER SPRING MD
20904-1663
US

IV. Provider business mailing address

12515 OLD GUNPOWDER RD
BELTSVILLE MD
20705-1151
US

V. Phone/Fax

Practice location:
  • Phone: 301-755-3380
  • Fax: 866-596-1084
Mailing address:
  • Phone: 301-908-2116
  • Fax: 866-596-1084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR142632
License Number StateMD

VIII. Authorized Official

Name: MRS. ELIZABETH N. OBI
Title or Position: PRESIDENT /OWNER
Credential: NURSE PRACTITIONER
Phone: 301-908-2116