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General NPI Number Information
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NPI Number | 1144986233
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Entity Type | Organization
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Legal Business Name | MEDICAL PRACTICES OF ANTIETAM, LLC
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Dates
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Enumeration Date | 11/12/2021
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Last Update Date | 10/26/2022
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Provider Practice Location Address
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Address Line | 187 THOMAS JOHNSON DR STE 1
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City | FREDERICK
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State | MD
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Zip | 21702-4445
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Country | US
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Telephone | 301-378-9421
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Fax |
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Provider Business Mailing Address
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Address Line | 187 THOMAS JOHNSON DR STE 1
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City | FREDERICK
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State | MD
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Zip | 21702-4445
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | JOSHUA REPAC
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Credential |
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Telephone | 301-790-9351
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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