Provider Demographics
NPI:1568973444
Name:MARYLAND RETINA INSTITUTE LLC
Entity Type:Organization
Organization Name:MARYLAND RETINA INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAZA
Authorized Official - Middle Name:MURTAZA
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-876-4900
Mailing Address - Street 1:2919 OLNEY SANDY SPRING RD STE D
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1589
Mailing Address - Country:US
Mailing Address - Phone:301-876-4900
Mailing Address - Fax:
Practice Address - Street 1:2919 OLNEY SANDY SPRING RD STE D
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832
Practice Address - Country:US
Practice Address - Phone:301-876-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1205098910OtherUNITEDHEALTHCARE
MD1205098910OtherMARYLAND PHYSICIANS CARE
MD49280003OtherCAREFIRST BLUECROSS BLUESHIELD
MD07207311OtherAMERIGROUP
MD1205098910OtherCIGNA
MD1205098910OtherHIGHMARK BLUESHIELD
MD658406300Medicaid