Provider Demographics
NPI:1619009222
Name:MARYLAND MEDICAL SUPPLY LC
Entity Type:Organization
Organization Name:MARYLAND MEDICAL SUPPLY LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SYDONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-944-1804
Mailing Address - Street 1:3912 SHENTON RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2206
Mailing Address - Country:US
Mailing Address - Phone:410-944-1804
Mailing Address - Fax:410-982-6432
Practice Address - Street 1:3912 SHENTON RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2206
Practice Address - Country:US
Practice Address - Phone:410-944-1804
Practice Address - Fax:410-982-6432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD376650100Medicaid