Healthcare Provider Details

I. General information

NPI: 1184461063
Provider Name (Legal Business Name): SHADY GROVE CHILDREN'S GAD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15001 SHADY GROVE RD
ROCKVILLE MD
20850-6352
US

IV. Provider business mailing address

1220 CARAWAY CT STE 1050
UPPER MARLBORO MD
20774-5338
US

V. Phone/Fax

Practice location:
  • Phone: 301-307-3333
  • Fax: 301-307-5555
Mailing address:
  • Phone: 301-494-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY WHEELER
Title or Position: CEO
Credential:
Phone: 301-494-3000