=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578763199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COSMETIC SURGERY FACILITY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2007
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 BELLONA AVE SUITE C
-----------------------------------------------------
City | LUTHERVILLE TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-5465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-494-8100
-----------------------------------------------------
Fax | 410-494-0815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 BELLONA AVE SUITE C
-----------------------------------------------------
City | LUTHERVILLE TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-5465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-494-8100
-----------------------------------------------------
Fax | 410-494-0815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RICARDO L RODRIGUEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 410-494-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | D41395
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A1462
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------