Provider Demographics
NPI:1770565731
Name:GASTROINTESTINAL ASSOCIATES OF MARYLAND PA
Entity type:Organization
Organization Name:GASTROINTESTINAL ASSOCIATES OF MARYLAND PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEGINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-645-8035
Mailing Address - Street 1:12070 OLD LINE CTR
Mailing Address - Street 2:STE 200
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2503
Mailing Address - Country:US
Mailing Address - Phone:301-645-8035
Mailing Address - Fax:301-645-5229
Practice Address - Street 1:6710 OXON HILL RD STE 305
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1117
Practice Address - Country:US
Practice Address - Phone:301-292-2300
Practice Address - Fax:301-292-8025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035197200Medicaid
MD155700900Medicaid
DC524722Medicare PIN