Healthcare Provider Details

I. General information

NPI: 1861932170
Provider Name (Legal Business Name): ADVANTIA HOLDINGS OF MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FOREST GLEN RD SUITE 500
SILVER SPRING MD
20910-1459
US

IV. Provider business mailing address

1525 WILSON BLVD SUITE 540
ARLINGTON VA
22209-2411
US

V. Phone/Fax

Practice location:
  • Phone: 202-315-5223
  • Fax:
Mailing address:
  • Phone: 202-315-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER GLASS
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 202-315-5223