Provider Demographics
NPI:1376796169
Name:GERIATRIC ASSOC BROOK
Entity Type:Organization
Organization Name:GERIATRIC ASSOC BROOK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-924-2811
Mailing Address - Street 1:18100 SLADE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20860-1313
Mailing Address - Country:US
Mailing Address - Phone:301-924-2811
Mailing Address - Fax:301-924-1200
Practice Address - Street 1:18100 SLADE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRING
Practice Address - State:MD
Practice Address - Zip Code:20860-1313
Practice Address - Country:US
Practice Address - Phone:301-924-2811
Practice Address - Fax:301-924-1200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKE GROVE FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-24
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD062M207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC513984Medicare PIN