Provider Demographics
NPI:1285750059
Name:SOUTHERN MARYLAND ORTHOPAEDIC & SPORTS MEDICI NE CENTER PC
Entity type:Organization
Organization Name:SOUTHERN MARYLAND ORTHOPAEDIC & SPORTS MEDICI NE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:301-475-5555
Mailing Address - Street 1:23000 MOAKLEY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-5555
Mailing Address - Fax:301-475-8535
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-5555
Practice Address - Fax:301-475-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD225731900Medicaid
MD2878OtherBCBS
MD225731900Medicaid