Healthcare Provider Details

I. General information

NPI: 1548406960
Provider Name (Legal Business Name): SURGICAL ASSOCIATES, CHARTERED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12070 OLD LINE CTR SUITE 306
WALDORF MD
20602-2513
US

IV. Provider business mailing address

7501 SURRATTS RD SUITE 303
CLINTON MD
20735-3362
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-8485
  • Fax: 301-868-0638
Mailing address:
  • Phone: 301-868-8485
  • Fax: 301-868-0638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH0061922
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD24644
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberD0059944
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberD26021
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003134
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR119098
License Number StateMD

VIII. Authorized Official

Name: MICHELLE BURTON
Title or Position: CREDENTIALING/CONTRACTS MANAGER
Credential:
Phone: 301-868-8485