Healthcare Provider Details

I. General information

NPI: 1851690515
Provider Name (Legal Business Name): AMERICAN SPINE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 12/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 KEY PKWY STE 104
FREDERICK MD
21702-4053
US

IV. Provider business mailing address

1050 KEY PKWY STE 202
FREDERICK MD
21702-4551
US

V. Phone/Fax

Practice location:
  • Phone: 240-629-3920
  • Fax: 240-629-3921
Mailing address:
  • Phone: 240-629-3920
  • Fax: 240-629-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberMDASSC
License Number StateMD

VIII. Authorized Official

Name: KHALID A KAHLOON
Title or Position: CEO
Credential:
Phone: 502-261-7200