MEDICARE: FREDERICK FAMILY MEDICAL CLINIC

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	207R00000X	Internal Medicine Physician	D0076463	MD

General Provider Information

NPI Number	:	1821585621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERICK FAMILY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	1709 ROSEMONT AVE
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21702-4135
Country	:	US
Telephone Number	:	301-624-5999
Fax Number	:	301-625-5997

Provider Business Practice Location Address
First Line	:	1709 ROSEMONT AVE
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21702-4135
Country	:	US
Telephone Number	:	301-624-5999
Fax Number	:	301-624-5997

Authorized Official
Title or Position	:	OWNER
Name	:	DR. INNOCENT MONYA-TAMBI
Credential	:	MD
Telephone Number	:	301-624-5999

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	04/07/2022

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