Provider Demographics
NPI:1679858443
Name:ADDIS ALEM MEDICINE, PLLC
Entity Type:Organization
Organization Name:ADDIS ALEM MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-494-6882
Mailing Address - Street 1:16501 SHADY GROVE RD
Mailing Address - Street 2:7275
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20898-9201
Mailing Address - Country:US
Mailing Address - Phone:240-494-6882
Mailing Address - Fax:202-403-0508
Practice Address - Street 1:7300 VAN DUSEN RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9463
Practice Address - Country:US
Practice Address - Phone:240-494-6882
Practice Address - Fax:202-403-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0069430207RC0200X
207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty