MEDICARE: UPPER CROSSROADS MEDICAL GROUP

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

General Provider Information

NPI Number	:	1104290261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPPER CROSSROADS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2412 BALDWIN MILL RD
Second Line	:
City	:	FALLSTON
State	:	MD
Zip	:	21047
Country	:	US
Telephone Number	:	410-557-9191
Fax Number	:	410-557-9191

Provider Business Practice Location Address
First Line	:	2412 BALDWIN MILL RD
Second Line	:
City	:	FALLSTON
State	:	MD
Zip	:	21047
Country	:	US
Telephone Number	:	410-557-9191
Fax Number	:	410-557-9191

Authorized Official
Title or Position	:	PHYSICIAN/PARTNER
Name	:	MRS. SALVACION GARIN LAZATIN
Credential	:	M.D.
Telephone Number	:	410-557-9191

Provider Enumeration Date	:	11/30/2015
Last Update Date	:	11/30/2015

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