Healthcare Provider Details

I. General information

NPI: 1679673297
Provider Name (Legal Business Name): FALLSGROVE SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14955 SHADY GROVE RD SUITE 125
ROCKVILLE MD
20850-8700
US

IV. Provider business mailing address

14955 SHADY GROVE RD SUITE 125
ROCKVILLE MD
20850-8700
US

V. Phone/Fax

Practice location:
  • Phone: 301-340-1495
  • Fax: 301-838-9712
Mailing address:
  • Phone: 301-340-1495
  • Fax: 301-838-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1435
License Number StateMD

VIII. Authorized Official

Name: DR. SIU TING NG-WAGNER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 301-340-1495