Provider Demographics
NPI:1710161534
Name:FAMILY MEDICAL CENTER PA
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHNY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:EDAPPULLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-774-8355
Mailing Address - Street 1:3416 OLANDWOOD CT
Mailing Address - Street 2:207
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832
Mailing Address - Country:US
Mailing Address - Phone:301-774-1231
Mailing Address - Fax:
Practice Address - Street 1:3416 OLANDWOOD CT
Practice Address - Street 2:207
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1372
Practice Address - Country:US
Practice Address - Phone:301-774-1231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD512396Medicare PIN
E40799Medicare UPIN