Provider Demographics
NPI:1023815065
Name:MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Entity type:Organization
Organization Name:MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:BUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-373-7905
Mailing Address - Street 1:24035 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-4871
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:1015 PRINCE FREDERICK BLVD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3193
Practice Address - Country:US
Practice Address - Phone:410-535-4116
Practice Address - Fax:410-414-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-27
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty