Provider Demographics
NPI:1245743202
Name:WEIGHTLOSS & SLEEP DISORDER CENTER OF MARYLAND LLC
Entity type:Organization
Organization Name:WEIGHTLOSS & SLEEP DISORDER CENTER OF MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:JAWAD
Authorized Official - Last Name:MIRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-810-4496
Mailing Address - Street 1:2105 TWIN PEAKS CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 OPAL CT STE 4&5
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5942
Practice Address - Country:US
Practice Address - Phone:301-745-6392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0083539261QS1200X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0098990Medicaid