Provider Demographics
NPI:1386131118
Name:ADVANCED GENERAL PRACTICE, LLC
Entity type:Organization
Organization Name:ADVANCED GENERAL PRACTICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-592-1780
Mailing Address - Street 1:10801 LOCKWOOD DR STE 140
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1559
Mailing Address - Country:US
Mailing Address - Phone:301-592-1780
Mailing Address - Fax:240-645-4013
Practice Address - Street 1:12501 PROSPERITY DR STE 330
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1655
Practice Address - Country:US
Practice Address - Phone:301-592-1780
Practice Address - Fax:240-645-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MHD0074695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD446936400Medicaid
MD280571YQNZOtherMARYLAND