Provider Demographics
NPI:1356598379
Name:WALDORF PRIMARY CARE LLC
Entity type:Organization
Organization Name:WALDORF PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KARLENE
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-638-0001
Mailing Address - Street 1:3460 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3240
Mailing Address - Country:US
Mailing Address - Phone:301-638-0001
Mailing Address - Fax:301-638-5454
Practice Address - Street 1:3460 OLD WASHINGTON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3240
Practice Address - Country:US
Practice Address - Phone:301-638-0001
Practice Address - Fax:301-638-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066434261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49353Medicare UPIN