Provider Demographics
NPI:1588731566
Name:DR ITSCOITZ SEGAL & GRAVINO PA
Entity type:Organization
Organization Name:DR ITSCOITZ SEGAL & GRAVINO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:ITSCOITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-681-9095
Mailing Address - Street 1:10313 GEORGIA AVENUE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902
Mailing Address - Country:US
Mailing Address - Phone:301-681-9095
Mailing Address - Fax:301-681-8156
Practice Address - Street 1:10313 GEORGIA AVENUE
Practice Address - Street 2:SUITE 307
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902
Practice Address - Country:US
Practice Address - Phone:301-681-9095
Practice Address - Fax:301-681-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0005568207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD779721400Medicaid
58030002OtherBLUE CROSS DC
KA62ITOtherBLUE CROSS MARYLAND
B94543Medicare UPIN
MD779721400Medicaid