Provider Demographics
NPI:1104963990
Name:SAM TELLAWI MD PA
Entity type:Organization
Organization Name:SAM TELLAWI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-749-5191
Mailing Address - Street 1:7700 OLD BRANCH AVE
Mailing Address - Street 2:SUITE B-102
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1628
Mailing Address - Country:US
Mailing Address - Phone:301-856-1960
Mailing Address - Fax:301-856-3206
Practice Address - Street 1:560 RIVERSIDE DR STE A206
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4704
Practice Address - Country:US
Practice Address - Phone:410-912-5640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC062048700OtherMEDICAL ASSISTANCE
VA1104963990OtherMEDICAID
DCA618OtherCAREFIRST
DCG02093OtherMEDICARE
MD632104600OtherMEDICAL ASSISTANCE
MD8556OtherCAREFIRST
MD248NOtherMEDICARE
GADN4447OtherRAILROAD MEDICARE
MDB93557Medicare UPIN