Provider Demographics
NPI:1790970259
Name:RONALD PRUSSICK, MD,PC
Entity Type:Organization
Organization Name:RONALD PRUSSICK, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUSSICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-657-3622
Mailing Address - Street 1:7930 OLD GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2425
Mailing Address - Country:US
Mailing Address - Phone:301-657-3622
Mailing Address - Fax:301-657-3633
Practice Address - Street 1:7930 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2425
Practice Address - Country:US
Practice Address - Phone:301-657-3622
Practice Address - Fax:301-657-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0041493174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG01307Medicare PIN
DCG00116Medicare PIN
MD698MMedicare PIN