Provider Demographics
NPI:1861605099
Name:ST. MARY'S MULTISPECIALITY PHYSICIANS
Entity type:Organization
Organization Name:ST. MARY'S MULTISPECIALITY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLIENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-828-8100
Mailing Address - Street 1:25500 POINT LOOKOUT ROAD
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650
Mailing Address - Country:US
Mailing Address - Phone:410-828-8100
Mailing Address - Fax:410-882-3310
Practice Address - Street 1:25500 POINT LOOKOUT ROAD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:410-828-8100
Practice Address - Fax:410-882-3310
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HOSPTIAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-07
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
537LMedicare PIN
MD537LMedicare ID - Type Unspecified