Provider Demographics
NPI:1780631556
Name:MATRIX HOUSE PHYSICIANS PA
Entity Type:Organization
Organization Name:MATRIX HOUSE PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NADEHZDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVALCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-552-8118
Mailing Address - Street 1:PO BOX 17301
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1301
Mailing Address - Country:US
Mailing Address - Phone:301-498-2922
Mailing Address - Fax:301-498-3074
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3595
Practice Address - Country:US
Practice Address - Phone:301-552-8118
Practice Address - Fax:301-498-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG479OtherBCBS GROUP PROVIDER #
MDLL77MAOtherBCBS GROUP PROVIDER #
MD055700500Medicaid
MDLL77MAOtherBCBS GROUP PROVIDER #