Healthcare Provider Details

I. General information

NPI: 1164404125
Provider Name (Legal Business Name): GASTROINTESTINAL ASSOCIATES OF MARYLAND PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 OLD WASHINGTON RD STE 201
WALDORF MD
20602-3235
US

IV. Provider business mailing address

3510 OLD WASHINGTON RD STE 201
WALDORF MD
20602-3235
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-8035
  • Fax: 301-645-5229
Mailing address:
  • Phone: 301-645-8035
  • Fax: 301-645-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: LEGINA MICHELLE GRAY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 301-645-8035