Provider Demographics
NPI:1144252859
Name:MARYLAND PHYSICIANS EDGE LLC
Entity type:Organization
Organization Name:MARYLAND PHYSICIANS EDGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-681-6772
Mailing Address - Street 1:1400 FOREST GLEN RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 FOREST GLEN RD
Practice Address - Street 2:SUITE 500
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1459
Practice Address - Country:US
Practice Address - Phone:301-681-6772
Practice Address - Fax:301-681-0672
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANTIA HOLDINGS OF MARYLAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-06
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1169261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD389616Medicare PIN
MD21C0001169Medicare Oscar/Certification