Provider Demographics
NPI:1174728851
Name:CLARKSBURG MED INC
Entity type:Organization
Organization Name:CLARKSBURG MED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARPAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANGAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-515-3333
Mailing Address - Street 1:23208 BREWERS TAVERN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4391
Mailing Address - Country:US
Mailing Address - Phone:301-515-3333
Mailing Address - Fax:301-515-3322
Practice Address - Street 1:23208 BREWERS TAVERN WAY
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-4391
Practice Address - Country:US
Practice Address - Phone:301-515-3333
Practice Address - Fax:301-515-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416697300Medicaid
DCG02790Medicare PIN
MD130447Medicare PIN