Provider Demographics
NPI:1982782686
Name:SOUTHERN MARYLAND PULMONARY & CRITICAL CARE, P.A.
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND PULMONARY & CRITICAL CARE, P.A.
Other - Org Name:SO. MD. PULMONARY & CRITICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SONG
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHON
Authorized Official - Suffix:
Authorized Official - Credentials:D12587
Authorized Official - Phone:301-645-3420
Mailing Address - Street 1:3575 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3269
Mailing Address - Country:US
Mailing Address - Phone:301-645-3420
Mailing Address - Fax:301-645-3423
Practice Address - Street 1:3575 OLD WASHINGTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3269
Practice Address - Country:US
Practice Address - Phone:301-645-3420
Practice Address - Fax:301-645-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD4760773207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD741232100Medicaid
MDCH4678OtherRAILROAD MEDICARE
MDH32239Medicare UPIN
MD549LMedicare PIN
MDCH4678OtherRAILROAD MEDICARE
MD741232100Medicaid
DCG02636Medicare PIN