MEDICARE: PREVENTMD

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1578150348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENTMD

Provider Business Mailing Address
First Line	:	7800 CENTRAL AVE
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-4807
Country	:	US
Telephone Number	:	410-804-7200
Fax Number	:	301-218-7916

Provider Business Practice Location Address
First Line	:	7800 CENTRAL AVE
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-4807
Country	:	US
Telephone Number	:	410-804-7200
Fax Number	:	301-218-7916

Authorized Official
Title or Position	:	OWNER
Name	:	RITA DELORES WUTOH
Credential	:	M.D.
Telephone Number	:	410-804-7200

Provider Enumeration Date	:	12/28/2020
Last Update Date	:	12/28/2020

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