Provider Demographics
NPI:1871198671
Name:MARYLAND PRIMARY CARE AND WELLNESS
Entity Type:Organization
Organization Name:MARYLAND PRIMARY CARE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT ENOW
Authorized Official - Middle Name:ENOW
Authorized Official - Last Name:TAKEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-408-6286
Mailing Address - Street 1:7100 LONGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-2120
Mailing Address - Country:US
Mailing Address - Phone:240-408-6286
Mailing Address - Fax:
Practice Address - Street 1:14314 OLD MARLBORO PIKE
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2840
Practice Address - Country:US
Practice Address - Phone:301-627-3500
Practice Address - Fax:301-627-1634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYLAND PRIMARY CARE AND WELLNESS,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD924025000Medicaid