MEDICARE: PRIME PEDIATRICS, 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	2080A0000X	Pediatric Adolescent Medicine Physician	D0058375	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316286032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	845 QUINCE ORCHARD BLVD STE B
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-1676
Country	:	US
Telephone Number	:	301-977-2440
Fax Number	:	301-977-4752

Provider Business Practice Location Address
First Line	:	845 QUINCE ORCHARD BLVD STE B
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20878-1676
Country	:	US
Telephone Number	:	301-977-2440
Fax Number	:	301-977-4752

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FARNOUSH JAMALI
Credential	:	M.D.
Telephone Number	:	301-977-2440

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	02/01/2013

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Directions to “PRIME PEDIATRICS, LLC ” Practice Location

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