Provider Demographics
NPI:1477639862
Name:OPAL MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:OPAL MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-420-6909
Mailing Address - Street 1:1126 OPAL COURT
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740
Mailing Address - Country:US
Mailing Address - Phone:240-420-2666
Mailing Address - Fax:240-420-0951
Practice Address - Street 1:1126 OPAL COURT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:240-420-2666
Practice Address - Fax:240-420-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD52323207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404343000Medicaid
G86887Medicare UPIN
MD404343000Medicaid