=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033524855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENT ISLAND SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2014
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1630 MAIN ST SUITE 215A
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21619-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-571-9000
-----------------------------------------------------
Fax | 410-571-1670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2661 RIVA RD BUILDING 100 SUITE 115
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-458-5132
-----------------------------------------------------
Fax | 443-221-7622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. BRIAN S KAHAN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 410-571-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------