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General NPI Number Information
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NPI Number | 1164580635
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Entity Type | Organization
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Legal Business Name | OLD LINE MEDICAL SERVICES, P.C.
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 12090 OLD LINE CTR
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City | WALDORF
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State | MD
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Zip | 20602-2556
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Country | US
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Telephone | 301-843-3888
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Fax | 301-870-6838
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Provider Business Mailing Address
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Address Line | 12090 OLD LINE CTR
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City | WALDORF
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State | MD
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Zip | 20602-2556
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Country | US
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Telephone | 301-843-3888
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Fax | 301-870-6838
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEPHEN EDWARD WIGGINS
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Credential | M.D.
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Telephone | 301-843-3888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State | MD
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