Basic Information
| Provider Information | |||||||||
| NPI: | 1730184599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOCRINE AND DIABETES ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6430 ROCKLEDGE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208171847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014681451 | ||||||||
| FaxNumber: | 3014683580 | ||||||||
| Practice Location | |||||||||
| Address1: | 6430 ROCKLEDGE DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208171847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014681451 | ||||||||
| FaxNumber: | 3014683580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | PETRICK | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3014681451 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | D0031800 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 5499011 | 05 | MD | MEDICAID |