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General NPI Number Information
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NPI Number | 1073534012
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE AMBULATORY SURG CENTER
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Dates
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Enumeration Date | 07/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 44045 RIVERSIDE PKWY
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City | LEESBURG
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State | VA
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Zip | 20176-5101
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Country | US
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Telephone | 703-858-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 4 PIDGEON HILL DR
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City | STERLING
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State | VA
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Zip | 20165-6101
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Country | US
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Telephone | 703-737-7513
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. JOHN GRISH
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Credential |
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Telephone | 703-858-6604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | OH 652
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License Number State | VA
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