Provider Demographics
NPI:1982280426
Name:MD MEDICAL GROUP
Entity Type:Organization
Organization Name:MD MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:JR MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-309-5992
Mailing Address - Street 1:68 1ST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-1288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:68 1ST AVE STE C
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-1288
Practice Address - Country:US
Practice Address - Phone:908-309-5992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty