Provider Demographics
NPI:1114314150
Name:MED-PED HEALTHCARE, LLC
Entity Type:Organization
Organization Name:MED-PED HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FADUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-345-4400
Mailing Address - Street 1:4701 MELBOURNE PLACE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740
Mailing Address - Country:US
Mailing Address - Phone:301-345-4400
Mailing Address - Fax:301-345-6200
Practice Address - Street 1:4701 MELBOURNE PL
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2540
Practice Address - Country:US
Practice Address - Phone:301-345-4400
Practice Address - Fax:301-345-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053745305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00445OtherMEDICARE PTAN