Provider Demographics
NPI:1558443762
Name:ANTIOCH PRIMARY CARE LLC
Entity type:Organization
Organization Name:ANTIOCH PRIMARY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-473-1090
Mailing Address - Street 1:4700 BERWYN HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740
Mailing Address - Country:US
Mailing Address - Phone:240-473-1090
Mailing Address - Fax:
Practice Address - Street 1:4700 BERWYN HOUSE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740
Practice Address - Country:US
Practice Address - Phone:240-473-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty