MEDICARE: PAX RIVER MEDICAL CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	H0055958	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1437267986	OTHER	MD	INDIVIDUAL NPI #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083807085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAX RIVER MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	46940 S SHANGRI LA DR
Second Line	:	SUITE #19
City	:	LEXINGTON PARK
State	:	MD
Zip	:	20653-1037
Country	:	US
Telephone Number	:	301-863-8101
Fax Number	:	301-863-8130

Provider Business Practice Location Address
First Line	:	46940 S SHANGRI LA DR
Second Line	:	SUITE #19
City	:	LEXINGTON PARK
State	:	MD
Zip	:	20653-1037
Country	:	US
Telephone Number	:	301-863-8101
Fax Number	:	301-863-8130

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KATHERINE ANN MARTIN
Credential	:	DO
Telephone Number	:	301-863-8101

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	05/09/2014

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