MEDICARE: MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND 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	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1609673649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC

Provider Business Mailing Address
First Line	:	24035 THREE NOTCH RD
Second Line	:
City	:	HOLLYWOOD
State	:	MD
Zip	:	20636-4871
Country	:	US
Telephone Number	:	301-373-7900
Fax Number	:	301-373-6900

Provider Business Practice Location Address
First Line	:	28030 OLD VILLAGE ROAD
Second Line	:
City	:	MECHANICSVILLE
State	:	MD
Zip	:	20659-3295
Country	:	US
Telephone Number	:	301-884-4666
Fax Number	:	301-884-5852

Authorized Official
Title or Position	:	C.O.O.
Name	:	ALAN ADAIR BUSTER
Credential	:
Telephone Number	:	301-373-7905

Provider Enumeration Date	:	02/27/2025
Last Update Date	:	08/01/2025

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