Provider Demographics
NPI:1114362845
Name:MARYLAND SPECIALTY GROUP LLC
Entity Type:Organization
Organization Name:MARYLAND SPECIALTY GROUP LLC
Other - Org Name:ULTIMA CARE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAGWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-552-9495
Mailing Address - Street 1:PO BOX 2056
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20718-2056
Mailing Address - Country:US
Mailing Address - Phone:301-552-9495
Mailing Address - Fax:301-552-9743
Practice Address - Street 1:12200 ANNAPOLIS RD
Practice Address - Street 2:STE 123
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-552-9495
Practice Address - Fax:301-552-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207V00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01686Medicare PIN