MEDICARE: GEORGE H WATHEN MD PA

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	174400000X	Specialist	D0020629	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG5923	OTHER		R R MEDICARE

General Provider Information

NPI Number	:	1710168836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE H WATHEN MD PA

Provider Business Mailing Address
First Line	:	11345 PEMBROOKE SQ
Second Line	:	SUITE 103
City	:	WALDORF
State	:	MD
Zip	:	20603-4804
Country	:	US
Telephone Number	:	301-645-8144
Fax Number	:	301-870-8392

Provider Business Practice Location Address
First Line	:	SUITE 103
Second Line	:	11345 PEMBROOKE SQ
City	:	WALDORF
State	:	MD
Zip	:	20603-4804
Country	:	US
Telephone Number	:	301-645-8144
Fax Number	:	301-870-8392

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GEORGE H WATHEN
Credential	:	MD PA
Telephone Number	:	301-645-8144

Provider Enumeration Date	:	11/16/2007
Last Update Date	:	02/15/2008

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