Provider Demographics
NPI:1306477849
Name:CENTENNIAL MEDICAL GROUP, PA
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:ELFENBEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-721-2333
Mailing Address - Street 1:5005 SIGNAL BELL LN STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-2608
Mailing Address - Country:US
Mailing Address - Phone:410-730-3399
Mailing Address - Fax:
Practice Address - Street 1:1071 MD RT 3 N STE 101
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1784
Practice Address - Country:US
Practice Address - Phone:410-721-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty