Provider Demographics
NPI:1831415868
Name:MARYLAND MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:MARYLAND MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRIDGERS
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-822-4383
Mailing Address - Street 1:995 HOSPITALITY WAY
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001
Mailing Address - Country:US
Mailing Address - Phone:410-306-7880
Mailing Address - Fax:410-306-7881
Practice Address - Street 1:995 HOSPITALITY WAY
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001
Practice Address - Country:US
Practice Address - Phone:410-306-7880
Practice Address - Fax:410-306-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM42628332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site