Provider Demographics
NPI:1841778784
Name:YOUR FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:YOUR FAMILY MEDICAL CENTER
Other - Org Name:YOUR FAMILY MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHI
Authorized Official - Middle Name:KRISHNAN
Authorized Official - Last Name:PRABHAKARAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-442-0908
Mailing Address - Street 1:4313 BEL PRE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-2050
Mailing Address - Country:US
Mailing Address - Phone:301-442-0908
Mailing Address - Fax:
Practice Address - Street 1:4313 BEL PRE RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20853-2050
Practice Address - Country:US
Practice Address - Phone:301-442-0908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR113675261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care