Provider Demographics
NPI:1083032445
Name:BOSTON MEDICAL GROUP- MARYLAND, P.C.
Entity Type:Organization
Organization Name:BOSTON MEDICAL GROUP- MARYLAND, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-808-2828
Mailing Address - Street 1:5500 KNOLL DRIVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045
Mailing Address - Country:US
Mailing Address - Phone:443-542-9241
Mailing Address - Fax:443-542-9442
Practice Address - Street 1:5500 KNOLL DRIVE
Practice Address - Street 2:SUITE 220
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:443-542-9241
Practice Address - Fax:443-542-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty