Healthcare Provider Details

I. General information

NPI: 1720322134
Provider Name (Legal Business Name): MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SAINT PATRICKS DR SUITE 203
WALDORF MD
20603-4527
US

IV. Provider business mailing address

10 SAINT PATRICKS DR SUITE 203
WALDORF MD
20603-4527
US

V. Phone/Fax

Practice location:
  • Phone: 301-843-0222
  • Fax: 301-843-0651
Mailing address:
  • Phone: 301-843-0222
  • Fax: 301-843-0651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORA KUCHKA-CRAIG
Title or Position: CORPORATE VICE PRESIDENT
Credential:
Phone: 410-772-6827