Provider Demographics
NPI:1295032852
Name:DIVINE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:DIVINE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:OPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-877-6194
Mailing Address - Street 1:214 FLINTSTONE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-2250
Mailing Address - Country:US
Mailing Address - Phone:443-877-6194
Mailing Address - Fax:443-877-6235
Practice Address - Street 1:214 FLINTSTONE DR
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-2250
Practice Address - Country:US
Practice Address - Phone:443-877-6194
Practice Address - Fax:443-877-6235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD217678OtherMEDICARE PTAN