Provider Demographics
NPI:1023424363
Name:GWMFA-MEDICAL FACULTY ASSOCIATES, INC
Entity type:Organization
Organization Name:GWMFA-MEDICAL FACULTY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROTKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-994-8650
Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:240-994-8650
Mailing Address - Fax:
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:240-994-8650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031061261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical