Provider Demographics
NPI:1881332088
Name:CENTREVILLE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:CENTREVILLE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LUNCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:410-778-1311
Mailing Address - Street 1:120 SPEER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1085
Mailing Address - Country:US
Mailing Address - Phone:410-778-1311
Mailing Address - Fax:410-778-0623
Practice Address - Street 1:120 SPEER RD STE 2
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1085
Practice Address - Country:US
Practice Address - Phone:410-778-1311
Practice Address - Fax:414-077-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1508800095Medicaid