=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023815065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2025
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 N PRINCE FREDERICK BLVD
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-3193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-4116
-----------------------------------------------------
Fax | 410-414-8480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24035 THREE NOTCH RD
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20636-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-373-7900
-----------------------------------------------------
Fax | 301-373-6900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.O.O.
-----------------------------------------------------
Name | ALAN ADAIR BUSTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-373-7905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------