Provider Demographics
NPI: | 1437317955 |
---|---|
Name: | FAMILY MEDICINE OF GAITHERSBURG |
Entity Type: | Organization |
Organization Name: | FAMILY MEDICINE OF GAITHERSBURG |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIR OF OPERATIONS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CARYL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MATTHEW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 301-216-2065 |
Mailing Address - Street 1: | 981 RUSSELL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | GAITHERSBURG |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 20879-6219 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 981 RUSSELL AVE |
Practice Address - Street 2: | |
Practice Address - City: | GAITHERSBURG |
Practice Address - State: | MD |
Practice Address - Zip Code: | 20879-6219 |
Practice Address - Country: | US |
Practice Address - Phone: | 301-740-8732 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-05-30 |
Last Update Date: | 2008-05-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 002760000 | Medicaid |