Provider Demographics
NPI:1396929931
Name:PRIYALLC
Entity type:Organization
Organization Name:PRIYALLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:RANI
Authorized Official - Last Name:MITTAR
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:410-719-9110
Mailing Address - Street 1:7001 JOHNNYCAKE RD
Mailing Address - Street 2:SUITE#200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2418
Mailing Address - Country:US
Mailing Address - Phone:410-719-9110
Mailing Address - Fax:410-719-9122
Practice Address - Street 1:7001 JOHNNYCAKE RD
Practice Address - Street 2:SUITE#200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2418
Practice Address - Country:US
Practice Address - Phone:410-719-9110
Practice Address - Fax:410-719-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669425179Medicare UPIN
MD810LMedicare PIN