Healthcare Provider Details

I. General information

NPI: 1700431368
Provider Name (Legal Business Name): SOMERVILLE SURGICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 CHARTER DR STE 200
COLUMBIA MD
21044-3629
US

IV. Provider business mailing address

310 LYON CT
PIKESVILLE MD
21208-1195
US

V. Phone/Fax

Practice location:
  • Phone: 410-446-7431
  • Fax: 410-910-2310
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN SOMERVILLE
Title or Position: OWNER
Credential: MD
Phone: 410-910-2310