Provider Demographics
NPI:1366489783
Name:SHADY GROVE HYPERBARIC MEDICINE
Entity Type:Organization
Organization Name:SHADY GROVE HYPERBARIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUZY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-826-7550
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21705-0856
Mailing Address - Country:US
Mailing Address - Phone:240-364-2515
Mailing Address - Fax:
Practice Address - Street 1:9901 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3357
Practice Address - Country:US
Practice Address - Phone:301-279-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD600303600Medicaid
MD600303600Medicaid