Healthcare Provider Details

I. General information

NPI: 1861339178
Provider Name (Legal Business Name): HEART CENTER OF SOUTHERN MARYLAND LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 PEMBROOKE SQ
WALDORF MD
20603-4842
US

IV. Provider business mailing address

PO BOX 316
WALDORF MD
20604-0316
US

V. Phone/Fax

Practice location:
  • Phone: 301-932-5890
  • Fax: 301-645-6361
Mailing address:
  • Phone: 301-932-5890
  • Fax: 301-645-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: STACI L BOWLING
Title or Position: MANAGER
Credential:
Phone: 301-932-5890