Provider Demographics
NPI:1194592220
Name:PRIMARY CARE OF MARYLAND PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PRIMARY CARE OF MARYLAND PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMPUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-930-0161
Mailing Address - Street 1:4155 GLEN PARK RD
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1019
Mailing Address - Country:US
Mailing Address - Phone:410-248-0661
Mailing Address - Fax:
Practice Address - Street 1:4155 GLEN PARK RD
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1019
Practice Address - Country:US
Practice Address - Phone:410-248-0661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health