Provider Demographics
NPI:1356957252
Name:PERIDOT PRIMARY CARE, LLC
Entity type:Organization
Organization Name:PERIDOT PRIMARY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PRINCESS
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-298-9919
Mailing Address - Street 1:23202 BREWERS TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4391
Mailing Address - Country:US
Mailing Address - Phone:301-298-9919
Mailing Address - Fax:301-298-9917
Practice Address - Street 1:23202 BREWERS TAVERN WAY
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4391
Practice Address - Country:US
Practice Address - Phone:301-215-2309
Practice Address - Fax:855-942-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty