Provider Demographics
NPI:1104940139
Name:CALVERT OBGYN ASSOCIATES OF SOUTHERN MARYLAND, LLC
Entity type:Organization
Organization Name:CALVERT OBGYN ASSOCIATES OF SOUTHERN MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:TIRALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-535-3642
Mailing Address - Street 1:110 HOSPITAL RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4019
Mailing Address - Country:US
Mailing Address - Phone:410-535-3642
Mailing Address - Fax:410-535-6836
Practice Address - Street 1:110 HOSPITAL RD
Practice Address - Street 2:SUITE 211
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4019
Practice Address - Country:US
Practice Address - Phone:410-535-3642
Practice Address - Fax:410-535-6836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2217716OtherAETNA US HEALTHCARE HMO
KAN9CAOtherBLUE SHIELD OF MARYLAND
366483OtherMAMSI - SUITE 202
6906-0000OtherBLUE SHIELD DC
367313OtherMAMSI - SUITE #211
7394046OtherAETNA US HEALTHCARE PPO
2217716OtherAETNA US HEALTHCARE HMO