Provider Demographics
NPI:1689472193
Name:MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Entity type:Organization
Organization Name:MEDSTAR MEDICAL GROUP - SOUTHERN MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:BUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-373-7905
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0640
Mailing Address - Country:US
Mailing Address - Phone:301-373-7900
Mailing Address - Fax:301-373-6900
Practice Address - Street 1:26840 PT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:301-475-5577
Practice Address - Fax:301-475-7419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty