Provider Demographics
NPI:1255302659
Name:ADVANCE INTERNAL MEDICINE P C
Entity Type:Organization
Organization Name:ADVANCE INTERNAL MEDICINE P C
Other - Org Name:ADVANCED INTERNAL MEDICINE P C
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAPHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-933-5050
Mailing Address - Street 1:18121 GEORGIA AVE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1437
Mailing Address - Country:US
Mailing Address - Phone:301-933-5050
Mailing Address - Fax:301-949-3262
Practice Address - Street 1:18121 GEORGE AVE
Practice Address - Street 2:SUITE #103
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-933-5050
Practice Address - Fax:301-949-3262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408708Medicare ID - Type Unspecified