=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831386630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MARYLAND PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 12/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3460 OLD WASHINGTON RD SUITE 203A
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-638-9670
-----------------------------------------------------
Fax | 301-638-7558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1558
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20604-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-638-9670
-----------------------------------------------------
Fax | 301-638-7558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NIRAN P SHARMA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-638-9670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D78727
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------