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General NPI Number Information
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NPI Number | 1275173031
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Entity Type | Organization
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Legal Business Name | PG COMMUNITYPEDIATRIC AND ADOLESCENT HEALTH CENTER INC.
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Dates
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Enumeration Date | 01/09/2020
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Last Update Date | 01/09/2020
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Provider Practice Location Address
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Address Line | 6122 LANDOVER RD
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City | CHEVERLY
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State | MD
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Zip | 20785-1016
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Country | US
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Telephone | 301-322-2411
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Fax |
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Provider Business Mailing Address
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Address Line | 8420 VICTORY LN
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City | POTOMAC
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State | MD
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Zip | 20854-3562
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Country | US
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Telephone | 301-980-6417
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MODUPE F ODUNUGA
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Credential | MD
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Telephone | 301-322-2411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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