Provider Demographics
NPI:1124484779
Name:SDM-1 STOP PRIMARY & URGENT CARE
Entity type:Organization
Organization Name:SDM-1 STOP PRIMARY & URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURE
Authorized Official - Middle Name:BERTILLE
Authorized Official - Last Name:NDEUTCHOUA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, DNP
Authorized Official - Phone:240-383-8705
Mailing Address - Street 1:6401 NEW HAMPSHIRE AVE
Mailing Address - Street 2:100
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3201
Mailing Address - Country:US
Mailing Address - Phone:301-466-3593
Mailing Address - Fax:240-764-5571
Practice Address - Street 1:6401 NEW HAMPSHIRE AVE
Practice Address - Street 2:100
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3201
Practice Address - Country:US
Practice Address - Phone:301-466-3593
Practice Address - Fax:240-764-5571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC261QD1600X
MDR187557261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC019178107Medicaid
DC014512051Medicaid