Provider Demographics
NPI:1104282409
Name:ERAN KESSOUS MD PC
Entity type:Organization
Organization Name:ERAN KESSOUS MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BOWIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-754-0505
Mailing Address - Street 1:11120 NEW HAMPSHIRE AVE
Mailing Address - Street 2:411
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2633
Mailing Address - Country:US
Mailing Address - Phone:301-754-0505
Mailing Address - Fax:301-754-0509
Practice Address - Street 1:11120 NEW HAMPSHIRE AVE
Practice Address - Street 2:411
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2633
Practice Address - Country:US
Practice Address - Phone:301-754-0505
Practice Address - Fax:301-754-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066523261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD182336OtherMEDICARE PTAN