=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558463257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHADY GROVE AMBULATORY SURGERY CENTER,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 08/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16220 S FREDERICK AVE SUITE 427
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20877-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-948-2995
-----------------------------------------------------
Fax | 301-948-6056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16220 S FREDERICK AVE SUITE 427
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20877-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-948-2995
-----------------------------------------------------
Fax | 301-948-6056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | RONALD ALLEN FOOTER
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 301-948-2995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A1135
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------