=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801790415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTEA MEDICAL MARYLAND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2026
-----------------------------------------------------
Last Update Date | 10/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 FURNACE ST
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21502-1564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-777-5941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 E RIVULON BLVD STE 103
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-0096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-408-7008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF RCM AND CONTRACTING
-----------------------------------------------------
Name | LISA KRUEGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-408-7008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------