Provider Demographics
NPI:1417717539
Name:MARYLAND PRIMARY CARE CLINIC LLC
Entity Type:Organization
Organization Name:MARYLAND PRIMARY CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:LATA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADHAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:352-745-4398
Mailing Address - Street 1:8114 SANDPIPER CIR STE 202
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5902
Mailing Address - Country:US
Mailing Address - Phone:352-745-4398
Mailing Address - Fax:
Practice Address - Street 1:8114 SANDPIPER CIR STE 202
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-5902
Practice Address - Country:US
Practice Address - Phone:352-745-4398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty