Provider Demographics
NPI:1598060709
Name:MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Entity Type:Organization
Organization Name:MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Other - Org Name:WALDORF ENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-868-3019
Mailing Address - Street 1:10403 HOSPITAL DR
Mailing Address - Street 2:SUITE G4
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3134
Mailing Address - Country:US
Mailing Address - Phone:301-868-3019
Mailing Address - Fax:301-856-9370
Practice Address - Street 1:10 SAINT PATRICKS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4527
Practice Address - Country:US
Practice Address - Phone:301-396-8071
Practice Address - Fax:301-396-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty