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?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002760000Medicaid