MEDICARE: MEDSTAR FAMILY CHOICE, INC

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	302F00000X	Exclusive Provider Organization

General Provider Information

NPI Number	:	1669604930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDSTAR FAMILY CHOICE, INC

Provider Business Mailing Address
First Line	:	8094 SANDPIPER CIR
Second Line	:	SUITE O
City	:	BALTIMORE
State	:	MD
Zip	:	21236-4907
Country	:	US
Telephone Number	:	410-933-3014
Fax Number	:	410-933-3019

Provider Business Practice Location Address
First Line	:	8094 SANDPIPER CIR
Second Line	:	SUITE O
City	:	BALTIMORE
State	:	MD
Zip	:	21236-4907
Country	:	US
Telephone Number	:	410-933-3014
Fax Number	:	410-933-3019

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. LESLEY WALLACE
Credential	:
Telephone Number	:	410-933-3013

Provider Enumeration Date	:	08/19/2009
Last Update Date	:	08/19/2009

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