Provider Demographics
NPI:1710427489
Name:PM FAMILYMED, LLC
Entity Type:Organization
Organization Name:PM FAMILYMED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERSKO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:410-841-8099
Mailing Address - Street 1:1208 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3801
Mailing Address - Country:US
Mailing Address - Phone:410-841-8099
Mailing Address - Fax:
Practice Address - Street 1:1208 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-3801
Practice Address - Country:US
Practice Address - Phone:410-841-8099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center