Basic Information
| Provider Information | |||||||||
| NPI: | 1023487873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATIENT FIRST MARYLAND MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PATIENT FIRST CLINTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 COX RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048224383 | ||||||||
| FaxNumber: | 8049650987 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 WOODYARD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207354206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405463428 | ||||||||
| FaxNumber: | 2405463429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRIDGERS | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 8048224383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | D0080205 | MD | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.