Provider Demographics
NPI:1457642068
Name:MARYLAND SKIN CARE CENTERS LLC
Entity Type:Organization
Organization Name:MARYLAND SKIN CARE CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGADEESH
Authorized Official - Middle Name:SV
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-930-0509
Mailing Address - Street 1:216 E PULASKI HWY
Mailing Address - Street 2:125
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6497
Mailing Address - Country:US
Mailing Address - Phone:443-485-6614
Mailing Address - Fax:410-286-1700
Practice Address - Street 1:216 E PULASKI HWY
Practice Address - Street 2:125
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6497
Practice Address - Country:US
Practice Address - Phone:443-485-6614
Practice Address - Fax:410-286-1700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067588207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty