Provider Demographics
NPI:1790953065
Name:POOLESVILLE FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:POOLESVILLE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AMAR
Authorized Official - Middle Name:VENKAT
Authorized Official - Last Name:DUGGIRALA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-972-7600
Mailing Address - Street 1:19710 FISHER AVE
Mailing Address - Street 2:SUITE J, PO BOX 108
Mailing Address - City:POOLESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20837-2098
Mailing Address - Country:US
Mailing Address - Phone:301-972-7600
Mailing Address - Fax:301-972-8006
Practice Address - Street 1:19710 FISHER AVE
Practice Address - Street 2:SUITE J
Practice Address - City:POOLESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20837-0108
Practice Address - Country:US
Practice Address - Phone:301-972-7600
Practice Address - Fax:301-972-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH61505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty