Provider Demographics
NPI:1578777611
Name:MEDLANTIC HEALTHCARE GROUP
Entity Type:Organization
Organization Name:MEDLANTIC HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-725-8753
Mailing Address - Street 1:PO BOX 631481
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1481
Mailing Address - Country:US
Mailing Address - Phone:443-725-8753
Mailing Address - Fax:
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:SUITE 4400
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2927
Practice Address - Country:US
Practice Address - Phone:202-877-6935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00107Medicare PIN