Healthcare Provider Details

I. General information

NPI: 1558492496
Provider Name (Legal Business Name): EYE SURGICAL CENTER OF BALTIMORE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 KENILWORTH DR SUITE 18
TOWSON MD
21204-2139
US

IV. Provider business mailing address

PO BOX 75221
BALTIMORE MD
21275-5221
US

V. Phone/Fax

Practice location:
  • Phone: 410-321-4400
  • Fax: 410-321-4909
Mailing address:
  • Phone: 410-321-4400
  • Fax: 410-321-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1150R
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. DOUGLAS R COLKITT
Title or Position: DIRECTOR
Credential: M.D.
Phone: 814-689-2066