Provider Demographics
NPI:1134508450
Name:MILL STREET MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:MILL STREET MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MALENA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-755-9488
Mailing Address - Street 1:340 MILL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6138
Mailing Address - Country:US
Mailing Address - Phone:301-739-7100
Mailing Address - Fax:301-498-1439
Practice Address - Street 1:340 MILL ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6138
Practice Address - Country:US
Practice Address - Phone:301-739-7100
Practice Address - Fax:301-498-1439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB67233Medicare UPIN