Healthcare Provider Details

I. General information

NPI: 1174074538
Provider Name (Legal Business Name): MIVC ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 CHERRY LANE
LAUREL MD
20707
US

IV. Provider business mailing address

8730 CHERRY LN SUITE 10
LAUREL MD
20707-6212
US

V. Phone/Fax

Practice location:
  • Phone: 301-497-1590
  • Fax:
Mailing address:
  • Phone: 301-497-1590
  • Fax:

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: DR. JEFFERY JARWRI DORMU
Title or Position: CEO/VASCULAR SURGEON
Credential: DO
Phone: 301-497-1590