Provider Demographics
NPI:1033990866
Name:MEDICAL PRACTICES OF ANTIETAM LLC
Entity Type:Organization
Organization Name:MEDICAL PRACTICES OF ANTIETAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-790-9351
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD STE 228
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 228
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6727
Practice Address - Country:US
Practice Address - Phone:301-733-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical