Healthcare Provider Details

I. General information

NPI: 1972658706
Provider Name (Legal Business Name): FREDERICKTOWN AMBULATORY SURGICAL FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 THOMAS JOHNSON DR SUITE 101
FREDERICK MD
21702-4398
US

IV. Provider business mailing address

198 THOMAS JOHNSON DR SUITE 101
FREDERICK MD
21702-4398
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-0870
  • Fax: 301-694-7034
Mailing address:
  • Phone: 301-694-0870
  • Fax: 301-694-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1166
License Number StateMD

VIII. Authorized Official

Name: DR. VINCENT EDWIN DIFABIO
Title or Position: PRESEIDENT
Credential: D.D.S.
Phone: 30169040870