Healthcare Provider Details

I. General information

NPI: 1043457468
Provider Name (Legal Business Name): MID ATLANTIC SKIN SURGERY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 SAINT PATRICKS DR SUITE 201
WALDORF MD
20603-5529
US

IV. Provider business mailing address

173 SAINT PATRICKS DR STE 201
WALDORF MD
20603-5531
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-8091
  • Fax: 301-472-6712
Mailing address:
  • Phone: 301-396-3401
  • Fax: 301-396-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE KANNARKAT VERGHESE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 301-396-3401