Provider Demographics
NPI:1245953009
Name:CENTENNIAL MEDICAL GROUP, PA
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP, PA
Other - Org Name:
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
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5803
Mailing Address - Country:US
Mailing Address - Phone:410-730-3399
Mailing Address - Fax:
Practice Address - Street 1:10120 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3614
Practice Address - Country:US
Practice Address - Phone:410-694-7999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-26
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty