=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023487873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATIENT FIRST MARYLAND MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9000 WOODYARD RD
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20735-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-546-3428
-----------------------------------------------------
Fax | 240-546-3429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 COX RD STE 100
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23060-9263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-822-4383
-----------------------------------------------------
Fax | 804-965-0987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, PHARMACY
-----------------------------------------------------
Name | MR. MARVIN W BRIDGERS III
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 804-822-4383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | D0080205
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------