Provider Demographics
NPI:1780629683
Name:MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Entity Type:Organization
Organization Name:MEDSTAR SOUTHERN MARYLAND PHYSICIANS, LLC
Other - Org Name:WALDORF FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-856-3019
Mailing Address - Street 1:10403 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE G-4
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3134
Mailing Address - Country:US
Mailing Address - Phone:301-856-3019
Mailing Address - Fax:301-856-9370
Practice Address - Street 1:10 ST PATRICKS DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4527
Practice Address - Country:US
Practice Address - Phone:301-843-0222
Practice Address - Fax:301-843-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty