Healthcare Provider Details

I. General information

NPI: 1942485305
Provider Name (Legal Business Name): 9106 PHILADELPHIA ROAD AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9106 PHILADELPHIA RD SUITE 306
BALTIMORE MD
21237
US

IV. Provider business mailing address

9106 PHILADELPHIA RD SUITE 306
BALTIMORE MD
21237
US

V. Phone/Fax

Practice location:
  • Phone: 410-687-2656
  • Fax: 410-687-3805
Mailing address:
  • Phone: 410-687-2656
  • Fax: 410-687-3805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GABRIEL MARTINEZ
Title or Position: OWNER/MD
Credential:
Phone: 410-687-2656