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General NPI Number Information
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NPI Number | 1831592211
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Entity Type | Organization
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Legal Business Name | MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
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Dates
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Enumeration Date | 09/30/2014
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Last Update Date | 08/12/2025
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Provider Practice Location Address
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Address Line | 24035 THREE NOTCH ROAD
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City | HOLLYWOOD
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State | MD
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Zip | 20636-4871
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Country | US
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Telephone | 301-373-7900
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Fax | 301-373-6900
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Provider Business Mailing Address
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Address Line | 24035 THREE NOTCH RD
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City | HOLLYWOOD
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State | MD
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Zip | 20636-4871
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Country | US
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Telephone | 301-373-7900
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Fax | 301-373-6900
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT
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Name | ERIC R WAGNER
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Credential |
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Telephone | 410-772-6595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #15
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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