Provider Demographics
NPI:1821585621
Name:FREDERICK FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:FREDERICK FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INNOCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MONYA-TAMBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-624-5999
Mailing Address - Street 1:1709 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4135
Mailing Address - Country:US
Mailing Address - Phone:301-624-5999
Mailing Address - Fax:301-625-5997
Practice Address - Street 1:1709 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4135
Practice Address - Country:US
Practice Address - Phone:301-624-5999
Practice Address - Fax:301-624-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076463207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty