21D0220530 CLIA NUMBER - PRAVEEN BOLARUM MD LLC

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Laboratory Demographics

CLIA Number: 21D0220530

Facility Name: PRAVEEN BOLARUM MD LLC

Facility Address:
196 THOMAS JOHNSON DRIVE SUITE 135
FREDERICK, MD
ZIP 21702
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Facility Phone Number: 301 694-6688

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1073575015

Taxonomy: 207Q00000X - Family Medicine
Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.

CLIA Record

Field Name	Field Value
CLIA Number	21D0220530
LAB Type	Physician Office
Facility Name	PRAVEEN BOLARUM MD LLC
Street	196 THOMAS JOHNSON DRIVE SUITE 135
City	FREDERICK
State	MD
ZIP	21702
Phone	301 694-6688
CertificateType	4
CertificateEffectiveDate	9/1/2022
CertificateExpirationDate	8/31/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024