Healthcare Provider Details

I. General information

NPI: 1053068809
Provider Name (Legal Business Name): WHITE SQUARE VASCULAR SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 04/07/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 W JOPPA RD STE 100
LUTHERVILLE MD
21093-4617
US

IV. Provider business mailing address

5233 KING AVE STE 208
BALTIMORE MD
21237-4003
US

V. Phone/Fax

Practice location:
  • Phone: 410-918-1525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AHMAD ABU-GHAIDA
Title or Position: MD OWNER
Credential:
Phone: 443-255-4750