Provider Demographics
NPI:1326274853
Name:PERSONAL PHYSICIAN CARE, LLC
Entity Type:Organization
Organization Name:PERSONAL PHYSICIAN CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-386-3381
Mailing Address - Street 1:6334 CEDAR LN STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3898
Mailing Address - Country:US
Mailing Address - Phone:410-531-2355
Mailing Address - Fax:
Practice Address - Street 1:6334 CEDAR LN STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3898
Practice Address - Country:US
Practice Address - Phone:410-531-2355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
04-03155OtherEVERCARE
MD380651100Medicaid
DPC6ALOtherBCBS
MD008203100Medicaid
KG01ER 53498303OtherCAREFIRST BCBS
153020ZDTSMedicare PIN
DPC6ALOtherBCBS
9860CMedicare PIN