Provider Demographics
NPI:1225226046
Name:FAMILY MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FAMILY MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-876-9785
Mailing Address - Street 1:332 140 VILLAGE RD
Mailing Address - Street 2:#167
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6196
Mailing Address - Country:US
Mailing Address - Phone:410-876-9785
Mailing Address - Fax:410-871-1988
Practice Address - Street 1:708C LISBON CENTER DR
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:MD
Practice Address - Zip Code:21797-8600
Practice Address - Country:US
Practice Address - Phone:410-795-7221
Practice Address - Fax:410-795-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR069707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP84773Medicare UPIN