=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710168836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE H WATHEN MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 02/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SUITE 103 11345 PEMBROOKE SQ
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20603-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-645-8144
-----------------------------------------------------
Fax | 301-870-8392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11345 PEMBROOKE SQ SUITE 103
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20603-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-645-8144
-----------------------------------------------------
Fax | 301-870-8392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEORGE H WATHEN
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 301-645-8144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | D0020629
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------