Provider Demographics
NPI:1083009658
Name:SERENITY MEDICAL & WELLNESS CENTER OF FREDERICK
Entity Type:Organization
Organization Name:SERENITY MEDICAL & WELLNESS CENTER OF FREDERICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BIANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:UDUGAMPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-331-6463
Mailing Address - Street 1:7820 WORMANS MILL RD STE B
Mailing Address - Street 2:SUITE 243
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3037
Mailing Address - Country:US
Mailing Address - Phone:240-651-5163
Mailing Address - Fax:
Practice Address - Street 1:801 TOLL HOUSE AVE
Practice Address - Street 2:SUITE F1
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4564
Practice Address - Country:US
Practice Address - Phone:240-561-5163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty