=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184058232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDSTAR URGENT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2013
-----------------------------------------------------
Last Update Date | 08/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12111 DARNESTOWN RD
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-926-3020
-----------------------------------------------------
Fax | 301-926-3021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12111 DARNESTOWN RD
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-926-3020
-----------------------------------------------------
Fax | 301-926-3021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE VICE PRESIDENT
-----------------------------------------------------
Name | DEBORAH KUCHKA-CRAIG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-772-6827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------