Healthcare Provider Details

I. General information

NPI: 1487280871
Provider Name (Legal Business Name): MARYLAND AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 FORBES BLVD STE 103
LANHAM MD
20706-6201
US

IV. Provider business mailing address

7501 FORBES BLVD STE 103
LANHAM MD
20706-6201
US

V. Phone/Fax

Practice location:
  • Phone: 202-498-1125
  • Fax: 240-770-0436
Mailing address:
  • Phone: 301-850-4401
  • Fax: 301-850-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRISTAN SHOCKLEY
Title or Position: OWNER
Credential:
Phone: 301-850-4401