Provider Demographics
NPI:1114935939
Name:PROFESSIONAL PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:CABATINGAN
Authorized Official - Last Name:MUNESES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-760-1010
Mailing Address - Street 1:7845 OAKWOOD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4280
Mailing Address - Country:US
Mailing Address - Phone:410-760-1010
Mailing Address - Fax:410-787-1056
Practice Address - Street 1:7845 OAKWOOD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4280
Practice Address - Country:US
Practice Address - Phone:410-760-1010
Practice Address - Fax:410-787-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLZ85PROtherBLUE SHIELD OF MD
MDLZ85PROtherBLUE SHIELD OF MD