Provider Demographics
NPI:1558832949
Name:FNP-BC VIP CONCIERGE, LLC
Entity Type:Organization
Organization Name:FNP-BC VIP CONCIERGE, LLC
Other - Org Name:NP-VIP CONCIERGE SVC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:DEVON
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:240-210-5520
Mailing Address - Street 1:8507 OXON HILL RD STE 200-S49
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-4766
Mailing Address - Country:US
Mailing Address - Phone:240-547-9114
Mailing Address - Fax:
Practice Address - Street 1:6178 OXON HILL RD STE 300
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3123
Practice Address - Country:US
Practice Address - Phone:240-547-9114
Practice Address - Fax:240-209-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1073965380Medicaid