Provider Demographics
NPI:1083807085
Name:PAX RIVER MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:PAX RIVER MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-863-8101
Mailing Address - Street 1:46940 S SHANGRI LA DR
Mailing Address - Street 2:SUITE #19
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-1037
Mailing Address - Country:US
Mailing Address - Phone:301-863-8101
Mailing Address - Fax:301-863-8130
Practice Address - Street 1:46940 S SHANGRI LA DR
Practice Address - Street 2:SUITE #19
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-1037
Practice Address - Country:US
Practice Address - Phone:301-863-8101
Practice Address - Fax:301-863-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0055958208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1437267986OtherINDIVIDUAL NPI #
MD011218600Medicaid
=========OtherIRS - GROUP TAX ID
MD011218600Medicaid
DC479PMedicare PIN