Provider Demographics
NPI:1154510154
Name:EDOMED MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:EDOMED MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUSA
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MOMOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-324-0078
Mailing Address - Street 1:PO BOX 10907
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20914-0907
Mailing Address - Country:US
Mailing Address - Phone:301-324-0078
Mailing Address - Fax:
Practice Address - Street 1:8700 CENTRAL AVE STE 301
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4853
Practice Address - Country:US
Practice Address - Phone:301-324-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD52900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01453Medicare PIN