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General NPI Number Information
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NPI Number | 1134508450
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Entity Type | Organization
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Legal Business Name | MILL STREET MEDICAL GROUP LLC
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Dates
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Enumeration Date | 05/19/2015
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Last Update Date | 04/01/2016
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Provider Practice Location Address
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Address Line | 340 MILL ST
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City | HAGERSTOWN
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State | MD
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Zip | 21740-6138
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Country | US
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Telephone | 301-739-7100
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Fax | 301-498-1439
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Provider Business Mailing Address
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Address Line | 340 MILL ST
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City | HAGERSTOWN
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State | MD
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Zip | 21740-6138
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Country | US
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Telephone | 301-739-7100
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Fax | 301-498-1439
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. MALENA JEAN-SMITH
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Credential |
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Telephone | 301-755-9488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | D0018019
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License Number State | MD
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