Provider Demographics
NPI:1760157713
Name:OLD GREENBELT FAMILY HEALTH
Entity Type:Organization
Organization Name:OLD GREENBELT FAMILY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-282-5040
Mailing Address - Street 1:115 CENTERWAY STE 104
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-1836
Mailing Address - Country:US
Mailing Address - Phone:866-282-5040
Mailing Address - Fax:609-482-8118
Practice Address - Street 1:115 CENTERWAY STE 104
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1836
Practice Address - Country:US
Practice Address - Phone:866-282-5040
Practice Address - Fax:609-482-8118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR235180OtherSTATE LICENSE