Healthcare Provider Details

I. General information

NPI: 1679757959
Provider Name (Legal Business Name): THOMAS JOHNSON SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2007
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 THOMAS JOHNSON DR
FREDERICK MD
21702-4314
US

IV. Provider business mailing address

197 THOMAS JOHNSON DR
FREDERICK MD
21702-4314
US

V. Phone/Fax

Practice location:
  • Phone: 301-631-3881
  • Fax: 301-631-3883
Mailing address:
  • Phone: 301-631-3881
  • Fax: 301-631-3883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1465
License Number StateMD

VIII. Authorized Official

Name: RAVI YALAMANCHILI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-846-0100