Provider Demographics
NPI:1710168836
Name:GEORGE H WATHEN MD PA
Entity Type:Organization
Organization Name:GEORGE H WATHEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WATHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:301-645-8144
Mailing Address - Street 1:11345 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4804
Mailing Address - Country:US
Mailing Address - Phone:301-645-8144
Mailing Address - Fax:301-870-8392
Practice Address - Street 1:SUITE 103
Practice Address - Street 2:11345 PEMBROOKE SQ
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4804
Practice Address - Country:US
Practice Address - Phone:301-645-8144
Practice Address - Fax:301-870-8392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020629174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG5923OtherR R MEDICARE
DG5923OtherR R MEDICARE
MD223N239GMedicare PIN
DCG02195Medicare PIN