Provider Demographics
NPI:1265688915
Name:CEDAR LANE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:CEDAR LANE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAFFEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-816-2480
Mailing Address - Street 1:11119 ROCKVILLE PIKE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3143
Mailing Address - Country:US
Mailing Address - Phone:301-816-2480
Mailing Address - Fax:301-816-2483
Practice Address - Street 1:11119 ROCKVILLE PIKE
Practice Address - Street 2:SUITE 316
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3143
Practice Address - Country:US
Practice Address - Phone:301-816-2480
Practice Address - Fax:301-816-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0045839261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF88459Medicare UPIN