1184481459 NPI number — MEDICAL PRACTICES OF ANTIETAM LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184481459 NPI number — MEDICAL PRACTICES OF ANTIETAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL PRACTICES OF ANTIETAM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MERITUS SPORTS MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184481459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11116 MEDICAL CAMPUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-6710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17301 VALLEY MALL RD STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21740-6966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-790-9237
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2024

Additional Information

Authorized Official

Authorized Official Last Name:
REPAC
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
301-790-9351

Provider Taxonomy Codes

  • Taxonomy code: 207RS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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