Provider Demographics
NPI:1134235039
Name:CENTENNIAL MEDICAL GROUP, PA
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJIV
Authorized Official - Middle Name:
Authorized Official - Last Name:DUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-730-3399
Mailing Address - Street 1:6230 OLD DOBBIN LN STE 230
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5884
Mailing Address - Country:US
Mailing Address - Phone:410-730-3399
Mailing Address - Fax:443-478-4737
Practice Address - Street 1:6250 OLD DOBBIN LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5816
Practice Address - Country:US
Practice Address - Phone:410-730-3399
Practice Address - Fax:443-478-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD470010400Medicaid
MDR481OtherBCBS
MD470010400Medicaid