=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508983115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUBURBAN ORTHOPAEDIC,TOTAL JOINT AND SPORTS CLINIC,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 04/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11701 LIVINGSTON RD SUITE 105
-----------------------------------------------------
City | FORT WASHINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20744-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-292-7447
-----------------------------------------------------
Fax | 301-292-3278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11701 LIVINGSTON RD SUITE 105
-----------------------------------------------------
City | FORT WASHINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20744-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-292-7447
-----------------------------------------------------
Fax | 301-292-3278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SAMIR NAGUIB AZER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-292-7447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | D0022051
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------