Provider Demographics
NPI:1568904712
Name:MID ATLANTIC MEDICAL MANAGEMENT , LLC
Entity Type:Organization
Organization Name:MID ATLANTIC MEDICAL MANAGEMENT , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATLEE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAMPLER IV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-524-6828
Mailing Address - Street 1:PO BOX 566455
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31156-6455
Mailing Address - Country:US
Mailing Address - Phone:770-504-5162
Mailing Address - Fax:
Practice Address - Street 1:3050 CRAIN HWY STE 101A
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2823
Practice Address - Country:US
Practice Address - Phone:240-754-7130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068492208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty