Provider Demographics
NPI:1154548303
Name:SOUTH RIVER PRIMARY CARE LLC
Entity type:Organization
Organization Name:SOUTH RIVER PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-956-7830
Mailing Address - Street 1:3168 BRAVERTON ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2674
Mailing Address - Country:US
Mailing Address - Phone:410-956-7830
Mailing Address - Fax:410-956-7832
Practice Address - Street 1:3168 BRAVERTON ST
Practice Address - Street 2:SUITE 330
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2674
Practice Address - Country:US
Practice Address - Phone:410-956-7830
Practice Address - Fax:410-956-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0056281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH51462Medicare UPIN