Healthcare Provider Details

I. General information

NPI: 1689749350
Provider Name (Legal Business Name): COLUMBIA UROLOGICAL SURGICAL CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11085 LITTLE PATUXENT PKWY SUITE 204
COLUMBIA MD
21044-2983
US

IV. Provider business mailing address

11085 LITTLE PATUXENT PKWY SUITE 207
COLUMBIA MD
21044-2983
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-5422
  • Fax: 410-997-4359
Mailing address:
  • Phone: 410-997-5422
  • Fax: 410-997-4359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1142
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License NumberA1142
License Number StateMD

VIII. Authorized Official

Name: DR. JOHN JOSEPH KISHEL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 410-997-5422