Provider Demographics
NPI:1982986519
Name:LAUREL PINE PEDIATRICS LLC
Entity Type:Organization
Organization Name:LAUREL PINE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WONDU
Authorized Official - Middle Name:T
Authorized Official - Last Name:WOSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-362-0506
Mailing Address - Street 1:14333 LAUREL BOWIE RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708
Mailing Address - Country:US
Mailing Address - Phone:301-362-0506
Mailing Address - Fax:301-362-6711
Practice Address - Street 1:14333 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708
Practice Address - Country:US
Practice Address - Phone:301-362-0506
Practice Address - Fax:301-362-6711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAUREL PINE PEDIATRICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD649741100Medicaid