Provider Demographics
NPI:1710327382
Name:SACRED HEART MEDICAL GROUP P.C.
Entity Type:Organization
Organization Name:SACRED HEART MEDICAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OBOITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-542-4810
Mailing Address - Street 1:6201 GREENBELT RD
Mailing Address - Street 2:SUITE U-15
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2354
Mailing Address - Country:US
Mailing Address - Phone:240-542-4810
Mailing Address - Fax:
Practice Address - Street 1:6201 GREENBELT RD
Practice Address - Street 2:SUITE U-15
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2354
Practice Address - Country:US
Practice Address - Phone:240-542-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068121207Q00000X, 207QG0300X
320700000X
DCMD0363613140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC022639M83Medicaid