Provider Demographics
NPI:1972922920
Name:MARYLAND PHYSICIANS EDGE LLC
Entity type:Organization
Organization Name:MARYLAND PHYSICIANS EDGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-398-0189
Mailing Address - Street 1:10750 COLUMBIA PIKE STE 700
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4461
Mailing Address - Country:US
Mailing Address - Phone:301-681-6772
Mailing Address - Fax:301-681-2618
Practice Address - Street 1:10750 COLUMBIA PIKE STE 700
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4461
Practice Address - Country:US
Practice Address - Phone:301-681-6772
Practice Address - Fax:301-681-2618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANTIA HOLDINGS OF MARYLAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-07
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD358975Medicare PIN