Healthcare Provider Details

I. General information

NPI: 1023162013
Provider Name (Legal Business Name): PENINSULA ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 OCEAN HIGHWAY
DELMAR MD
21875-2339
US

IV. Provider business mailing address

9315 OCEAN HIGHWAY
DELMAR MD
21875-2339
US

V. Phone/Fax

Practice location:
  • Phone: 410-896-9005
  • Fax: 410-896-9337
Mailing address:
  • Phone: 410-896-9005
  • Fax: 410-896-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number014352
License Number StateMD

VIII. Authorized Official

Name: DR. KOTA L CHANDRASEKHARA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 410-896-9005