Provider Demographics
NPI:1700861259
Name:MIDDLETOWN VALLEY FAMILY MEDICINE, P.A.
Entity Type:Organization
Organization Name:MIDDLETOWN VALLEY FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAITHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-371-9000
Mailing Address - Street 1:300 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-8043
Mailing Address - Country:US
Mailing Address - Phone:301-371-9000
Mailing Address - Fax:301-371-8905
Practice Address - Street 1:300 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:MD
Practice Address - Zip Code:21769-8043
Practice Address - Country:US
Practice Address - Phone:301-371-9000
Practice Address - Fax:301-371-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD913961300Medicaid
MDH569OtherBCBS GROUP NUMBER
MDH931OtherBCBS DC GROUP #
MDCE3202Medicare PIN
MDH569Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER