Provider Demographics
NPI:1497935605
Name:ADULT AND PEDIATRIC CLINIC, PC
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-453-0000
Mailing Address - Street 1:14816 PHYSICIANS LN
Mailing Address - Street 2:SUITE 152
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3944
Mailing Address - Country:US
Mailing Address - Phone:240-453-0000
Mailing Address - Fax:240-453-0089
Practice Address - Street 1:14816 PHYSICIANS LN
Practice Address - Street 2:SUITE 152
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3944
Practice Address - Country:US
Practice Address - Phone:240-453-0000
Practice Address - Fax:240-453-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061382208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002543700Medicaid
G01826Medicare PIN
G56524Medicare UPIN