Provider Demographics
NPI:1457308090
Name:CROFTON MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CROFTON MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRZA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NUSAIREE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-721-2700
Mailing Address - Street 1:1667 CROFTON CTR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1303
Mailing Address - Country:US
Mailing Address - Phone:410-721-2700
Mailing Address - Fax:410-721-8874
Practice Address - Street 1:1667 CROFTON CTR
Practice Address - Street 2:SUITE 5
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1303
Practice Address - Country:US
Practice Address - Phone:410-721-2700
Practice Address - Fax:410-721-8874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty