Provider Demographics
NPI:1336231950
Name:INTERNAL MEDICINE PRACTICE, P.A.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KODUAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPRAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-996-7900
Mailing Address - Street 1:18300 THUNDERCLOUD RD
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4380
Mailing Address - Country:US
Mailing Address - Phone:301-540-2076
Mailing Address - Fax:301-540-5073
Practice Address - Street 1:324 E ANTIETAM ST STE 306
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5768
Practice Address - Country:US
Practice Address - Phone:301-739-0240
Practice Address - Fax:301-797-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD336619700Medicaid
MDH71860Medicare UPIN
MD135NMedicare ID - Type Unspecified