Healthcare Provider Details

I. General information

NPI: 1982457321
Provider Name (Legal Business Name): WHITE SQUARE VASCULAR SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8817 BELAIR RD STE 109
NOTTINGHAM MD
21236-2445
US

IV. Provider business mailing address

5233 KING AVE STE 208
ROSEDALE MD
21237-4003
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-3325
  • Fax:
Mailing address:
  • Phone: 141-091-8152
  • Fax: 410-918-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NBIAL ABU-GHAIDA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 410-918-1525