Provider Demographics
NPI:1134461940
Name:AGAS MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:AGAS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:301-483-7999
Mailing Address - Street 1:9811 MALLARD DR
Mailing Address - Street 2:SUITE # 213
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3143
Mailing Address - Country:US
Mailing Address - Phone:301-604-0562
Mailing Address - Fax:240-840-9533
Practice Address - Street 1:9811 MALLARD DR
Practice Address - Street 2:SUITE # 213
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3143
Practice Address - Country:US
Practice Address - Phone:301-604-0562
Practice Address - Fax:240-840-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034747208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD010167200Medicaid