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General NPI Number Information
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NPI Number | 1568917383
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Entity Type | Organization
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Legal Business Name | HEART CENTER OF SOUTHERN MARYLAND
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 3510 OLD WASHINGTON RD SUITE 100
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City | WALDORF
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State | MD
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Zip | 20602-3233
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Country | US
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Telephone | 301-645-4793
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Fax |
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Provider Business Mailing Address
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Address Line | 3510 OLD WASHINGTON RD SUITE 100
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City | WALDORF
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State | MD
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Zip | 20602-3233
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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 | CEO
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Name | GOPALAKRISHNAN SRINIVASAN
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Credential | M.D
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Telephone | 301-645-4793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | MD
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