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General NPI Number Information
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NPI Number | 1508986092
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Entity Type | Organization
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Legal Business Name | BLACKWATER MEDICAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 408 BYRN ST
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City | CAMBRIDGE
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State | MD
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Zip | 21613-1910
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Country | US
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Telephone | 410-228-1068
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Fax |
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Provider Business Mailing Address
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Address Line | 408 BYRN ST
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City | CAMBRIDGE
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State | MD
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Zip | 21613-1910
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Country | US
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Telephone | 410-228-1068
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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. MARK M MALKUS
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Credential | M.D.
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Telephone | 410-228-1068
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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 | D0050804
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License Number State | MD
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