Provider Demographics
NPI:1639325319
Name:MARY K. CRADDOCK MD PC
Entity Type:Organization
Organization Name:MARY K. CRADDOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-317-0020
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-0639
Mailing Address - Country:US
Mailing Address - Phone:301-317-0020
Mailing Address - Fax:301-317-0028
Practice Address - Street 1:5550 FRIENDSHIP BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-7256
Practice Address - Country:US
Practice Address - Phone:301-215-7347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044988207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC6379OtherCAREFIRST
DC6379OtherCAREFIRST