Healthcare Provider Details

I. General information

NPI: 1902959190
Provider Name (Legal Business Name): RIVA ROAD SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 RIVA RD STE 118
ANNAPOLIS MD
21401-7430
US

IV. Provider business mailing address

2635 RIVA RD STE 118
ANNAPOLIS MD
21401-7430
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-9595
  • Fax: 410-571-9590
Mailing address:
  • Phone: 410-571-9595
  • Fax: 410-571-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberPENDING
License Number StateMD

VIII. Authorized Official

Name: NIKKI CASTEL
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 808-772-7818