Provider Demographics
NPI:1447007760
Name:PEDIATRIX MEDICAL GROUP OF THE MID-ATLANTIC PC
Entity type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP OF THE MID-ATLANTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-384-0175
Mailing Address - Street 1:PO BOX 100445
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7704 MATAPEAKE BUSINESS DR STE 315
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3046
Practice Address - Country:US
Practice Address - Phone:301-856-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-03
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD287003704Medicaid