Provider Demographics
NPI:1538134747
Name:LANDMARK MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:LANDMARK MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-638-5101
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-0667
Mailing Address - Country:US
Mailing Address - Phone:410-638-5101
Mailing Address - Fax:410-638-6854
Practice Address - Street 1:615 W MACPHAIL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4309
Practice Address - Country:US
Practice Address - Phone:410-638-5101
Practice Address - Fax:410-638-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207Q00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD968102701Medicaid
MDLN93OtherCAREFIRST BC/BS
MD852LMedicare ID - Type UnspecifiedMEDICARE PROVIDER #