Basic Information
| Provider Information | |||||||||
| NPI: | 1871594846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREATIVE LIFESTYLES MANAGEMENT PROG | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASTHMA/ALLERGY CENTER OF SOUTHERN MARYLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7503 SURRATTS ROAD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Practice Location | |||||||||
| Address1: | 7501 SURRATTS ROAD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018774616 | ||||||||
| FaxNumber: | 3018774355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHIARAMONTE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3018774530 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PRESIDENT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.