=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508355470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL ASSOCIATES CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2018
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11370 PEMBROOKE SQ
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20603-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-427-1620
-----------------------------------------------------
Fax | 301-645-8663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 ALLENTOWN RD STE 502
-----------------------------------------------------
City | CAMP SPRINGS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20746-4653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-427-1630
-----------------------------------------------------
Fax | 240-492-2070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MRS. RITA GROVER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 240-427-1630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------