Healthcare Provider Details

I. General information

NPI: 1912993700
Provider Name (Legal Business Name): PEMBROOKE SQUARE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 PEMBROOKE SQ
WALDORF MD
20603-4842
US

IV. Provider business mailing address

11370 PEMBROOKE SQ
WALDORF MD
20603-4842
US

V. Phone/Fax

Practice location:
  • Phone: 301-396-8492
  • Fax: 301-396-8498
Mailing address:
  • Phone: 301-396-8492
  • Fax: 301-396-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA1407
License Number StateMD

VIII. Authorized Official

Name: MRS. LISA F CONLEY
Title or Position: BUSINESS OFFICE MANAGER
Credential: CPC-H
Phone: 301-396-8492