Healthcare Provider Details

I. General information

NPI: 1578763199
Provider Name (Legal Business Name): COSMETIC SURGERY FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2007
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BELLONA AVE SUITE C
LUTHERVILLE TIMONIUM MD
21093-5465
US

IV. Provider business mailing address

1300 BELLONA AVE SUITE C
LUTHERVILLE TIMONIUM MD
21093-5465
US

V. Phone/Fax

Practice location:
  • Phone: 410-494-8100
  • Fax: 410-494-0815
Mailing address:
  • Phone: 410-494-8100
  • Fax: 410-494-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD41395
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1462
License Number StateMD

VIII. Authorized Official

Name: DR. RICARDO L RODRIGUEZ
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 410-494-8100