Provider Demographics
NPI:1578371514
Name:MARYLAND PRIMARY CARE AND WELLNESS
Entity type:Organization
Organization Name:MARYLAND PRIMARY CARE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:ENOW
Authorized Official - Last Name:TAKEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-408-6286
Mailing Address - Street 1:3921 FERRARA DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-4709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3921 FERRARA DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-4709
Practice Address - Country:US
Practice Address - Phone:301-946-6420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD924025000Medicaid
MD924034900Medicaid