=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255347050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND EYE SURGERY CENTER, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 PRINCE FREDERICK BLVD.
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-2270
-----------------------------------------------------
Fax | 410-535-5749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 PRINCE FREDERICK BLVD.
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-2270
-----------------------------------------------------
Fax | 410-535-5749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. DONALD BARTNICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-535-2270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A1333
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------