Provider Demographics
NPI:1952732430
Name:MARYLAND HEALTHCARE PC
Entity Type:Organization
Organization Name:MARYLAND HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG VICTOR
Authorized Official - Middle Name:IGOT
Authorized Official - Last Name:TAMPUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-248-0661
Mailing Address - Street 1:216 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-5941
Mailing Address - Country:US
Mailing Address - Phone:410-248-0661
Mailing Address - Fax:410-248-9771
Practice Address - Street 1:4155 GLEN PARK RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1019
Practice Address - Country:US
Practice Address - Phone:410-248-0661
Practice Address - Fax:443-219-9771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0076580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356679138Medicaid
VA1356679138Medicaid