Provider Demographics
NPI:1487751608
Name:GARRETT MEDICAL GROUP, PA
Entity type:Organization
Organization Name:GARRETT MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-334-8171
Mailing Address - Street 1:311 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1395
Mailing Address - Country:US
Mailing Address - Phone:301-334-8171
Mailing Address - Fax:301-334-1807
Practice Address - Street 1:311 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1395
Practice Address - Country:US
Practice Address - Phone:301-334-8171
Practice Address - Fax:301-334-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0006936000Medicaid
WV9317811Medicare PIN
WV0006936000Medicaid