Provider Demographics
NPI:1801989942
Name:MONTGOMERY PHYSICIAN ASSOCIATES PC
Entity type:Organization
Organization Name:MONTGOMERY PHYSICIAN ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-948-0098
Mailing Address - Street 1:19241 MONTGOMERY VILLAGE AVENUE
Mailing Address - Street 2:STE E23
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5036
Mailing Address - Country:US
Mailing Address - Phone:301-948-0098
Mailing Address - Fax:301-926-9180
Practice Address - Street 1:19241 MONTGOMERY VILLAGE AVENUE
Practice Address - Street 2:STE E23
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-5036
Practice Address - Country:US
Practice Address - Phone:301-948-0098
Practice Address - Fax:301-926-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031720207R00000X, 207RE0101X
MDD0040860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD201502100Medicaid
001256Medicare ID - Type Unspecified
E87985Medicare UPIN