Provider Demographics
NPI:1225644701
Name:MIRACLE MEDICAL LLC
Entity Type:Organization
Organization Name:MIRACLE MEDICAL LLC
Other - Org Name:MIRACLE MEDICAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICINE
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ALTAMARIA
Authorized Official - Last Name:MAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:240-603-0502
Mailing Address - Street 1:6005 LANDOVER RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1145
Mailing Address - Country:US
Mailing Address - Phone:240-687-8690
Mailing Address - Fax:
Practice Address - Street 1:6005 LANDOVER RD STE 5
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1145
Practice Address - Country:US
Practice Address - Phone:240-603-0502
Practice Address - Fax:443-790-9236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-19
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD766166500Medicaid