Provider Demographics
NPI:1942448113
Name:SOUTHERN MARYLAND MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GIRISH
Authorized Official - Middle Name:SADASHIVA
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-552-1200
Mailing Address - Street 1:8116 GOOD LUCK RD STE 305
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3508
Mailing Address - Country:US
Mailing Address - Phone:301-552-1200
Mailing Address - Fax:301-552-1202
Practice Address - Street 1:7500 GREENWAY CENTER DR STE 1200
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3556
Practice Address - Country:US
Practice Address - Phone:301-486-7580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149381OtherHIGHMARK MEDICARE