Provider Demographics
NPI:1477338325
Name:CENTENNIAL MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RIA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-730-3399
Mailing Address - Street 1:8186 LARK BROWN RD
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6433
Mailing Address - Country:US
Mailing Address - Phone:410-730-3399
Mailing Address - Fax:
Practice Address - Street 1:6742 DORSEY RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6205
Practice Address - Country:US
Practice Address - Phone:443-698-8664
Practice Address - Fax:443-338-8860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-29
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy